Sample neuro exam documentation: free download. On-line document store on 5y1.org

[DOC File]Family Practice History and Physical
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NL male/ female exam Endocrine. No thyroid disease or diabetes Rectal. Heme negative, normal prostate Hematologic. No easy bruising or bleeding Lymph. Neck, Axilla, Groin Psychiatric. No h/o anxiety, depression, mental illness MSK. strength 5/5, tone, gait, FROM Allergies: No hayfever, runny nose. Back . neg. SLR test x2, no scoliosis, no spasm
neuro assessment documentation

[DOC File]SOCIAL ASSESSMENT REPORT/SOCIAL HISTORY
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If you obtained documentation from a reliable professional source, which documents a specific aspect of a client’s history, you should cite the source of the information and use the language in the report rather than interpret the information. Conciseness – Be as concise as possible in your narrative. Avoid redundancy and unnecessary words.
neuro exam sample note

[DOC File]LAB 4: NEURO - Carle Illinois College of Medicine
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Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case. ... synched 1/10 with “Neuro_PE_1-9-10” and Bates 10th ed. p 710. Title: LAB 4: NEURO Last ...
neuro physical exam template

[DOCX File]UW Obstetrics and Gynecology - Homepage
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A bimanual exam was performed, which revealed an approximately ***-week size *** anteverted uterus with no palpable adnexal masses, cervical motion tenderness, or abnormalities. On speculum exam, there were no abnormalities in her vaginal epithelium. Her cervix was easily visualized and thought to be within normal limits.
neuro exam documentation template

[DOCX File]Department of Emergency Medicine | University of Washington
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Physical Exam. Level 1 – one system. Level 2-3 – 2 systems. Level 4 – 5 systems. Level 5 – 8 systems. High Acuity caveat documentation-- it is acceptable to use these phrases when appropriate if you are unable to complete portions of the HPI or PE: unable to obtain history due to … unable to perform full exam due to … (crashed to OR ...
basic neuro check form

[DOC File]N703 Chronic SOAP Note - Weebly
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Neuro: CN II – XII intact, sensory intact, strength equal bilaterally, no tremors or nystagmus noted. Psych: Alert and oriented X3. Recent and remote memory intact. Romberg: no drift. Gait strong and steady. Flat affect. Pt. appears quiet and distant. Labs: TC – 269. TG – 62. HDL – 75. LDL – 182. ALT/ AST – 21. GLU – 97. TSH – 3 ...
neuro exam physical exam documentation

[DOC File]M21-4, Appendix D - Veterans Affairs
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Nov 02, 2015 · Tracked Item Suspense Date Rules if linked to pending tracked item. VA/Contract Exam Requested, Awaiting Results Tracked Item Tracked Item Suspense Date Rules Section IV. Deferral Reasons. Introduction This section contains information about deferral reasons, including. purpose of deferral reasons, and. index of deferral reasons.
sample neuro exam write up

[DOC File]MUSCULOSKELTAL SAMPLE WRITE-UP
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MUSCULOSKELTAL SAMPLE WRITE-UP. Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case.
neuro assessment documentation sample

Sample neuro exam documentation