Sample patient diagnosis
[DOC File]MEDICAL RECORD REVIEW WORKSHEET
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Patient’s Name A0107) Admitting diagnosis A0027) Admitting Physician on staff A0106) H&P - 7 days prior or 48 hrs after admission A0112/A0113) Discharge summary/ diagnosis within 30 days after disch.
[DOC File]SAMPLE GOALS AND OBJECTIVES - DecisionHealth
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Patient will identify two coping skills related to (specific stressor) Patient will report at least six hours of restful sleep each night. Patient will eat at least two out of three meals a day to gain weight. Patient will attend at least two activities or groups a day. Patient will …
[DOC File]PSYCHIATRIC EVALUATION
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The patient was referred by (his, her) (therapist, casemanager, doctor), _____, for a psychiatric assessment and medication evaluation. The symptoms/problems/diagnosis identified were: Symptoms specified as possibly requiring medication were: The patient’s …
[DOC File]Standardized Patient Case Template
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Actual diagnosis / feasible diagnoses: Case Challenges: (check all that apply) [ ] medical interview [ ] physical examination [ ] patient counseling ... (patient in sitting position) [ ] inspect anterior chest (including breast inspection in women) [ ] palpate supraclavicular area for adenopathy [ ] palpate axillae for adenopathy [ ] percuss ...
[DOCX File]Using Complete Blood Cell Counts to Diagnose Disease
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Read each patient complaint. A blood smear sample in a hemocytometer grid has been provided, as well as information on any additional abnormal observations that may help in a diagnosis. Follow the directions to perform a red blood cell, white blood cell, and platelet count.
[DOC File]Sample Medical Records documentation
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A provisional diagnosis is recorded before the operative procedure by a licensed independent practitioner (LIP) responsible for the patient. (JCAHO IM 6.30 EOP #1) An operative progress note should be dated and timed and entered in the medical record immediately after the procedure and the note contains the following: (JCAHO IM 6.30 EOP #2)
[DOC File]Sample Nursing Care Plan
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Assessment Nursing Diagnosis Patient. Outcomes Interventions Rationale Evaluation of Outcomes 4. Experience a wound that decreases in size and has increased granulation tissue. 5. Achieve functional pain goal of zero by 1/24 per patient’s verbalizations. 4.
[DOC File]Attachment A: Sample Diagnosis and/or Treatment Plan
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15 x 37.00 =$555 Medical Assistance Out-patient pharmacy March-September, 2008 Various (or list if known) $5,000 Medical Assistance Out-patient laboratory $500 …
DOCTOR'S FORM LETTER - Medical home
If the underlying diagnosis of the incapacity is that of "senility", please describe the precise physical and mental condition underlying the diagnosis of senility. Is mental retardation the basis of the Proposed Ward's incapacity?
[DOC File]Topic - Pinson & Tang
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May 09, 2018 · Sample Clinical Documentation Query Templates. Table of Contents. Template Topics ... Clarification of conflicting diagnosis Clinical findings without a diagnosis Clinical validation (with example for sepsis) ... This patient was admitted with a UTI and also has a urinary catheter.
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