01-29-2009, 04:24 PM
can somebody help me with a sample patient note ? tnks.....
patient note - abdullahk85
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01-29-2009, 04:24 PM
can somebody help me with a sample patient note ? tnks.....
01-29-2009, 04:35 PM
Write bullet format:
HPI;10 sign or symptom + or - PMH;only name them SH,see usmle sample FH,very easy only words like;mother has RA PE,See sample note Ddx; u should get from pt Workup, //
01-29-2009, 04:42 PM
SHx; EX SMOKER*3 (1PPD*25 YRS)
It means pt has quit smoking Since 3 years and has been smoker for 25 years 1PPD
01-31-2009, 03:07 PM
is there any advise to improve patient note
01-31-2009, 03:21 PM
The note format...
cc: HPI: PMH: which should include medical hx, surgical hx, and any hospitalizations (so this knocks off the H in the 'HUGS') All: Meds: FHx: SHx: this includes sexual hx ObHx: you can have a separate section if its relevant to the SP, like if you think shes pregnant or something. ROS: should include the U, G, S, and everything else (I start from the skin, wt changes, energy level, head and go down) PE VS: WNL, BP 140/96 (so I wrote wnl unless something was not, then I just wrote it next to wnl) GA: HEENT: CVS: Lungs: Abd: Ext: CNS: At minimum I did VS, GA,CVS, Lungs, and Abd (though like I told you before I forgot to write anything about the VS in HALF my notes). You should try and write as much as you do, though you may forget. I didnt write during my PE cause it takes too much time and I DID forget things I examined. Just try and think about what the pt is complaining of and what is relevant and make sure you include that as a priority. Everything else, though should be there, is only a matter of completeness, and to make sure you are thinking on a multi-system level. If you do examine the extremities, you should put it in your note....if you did motor, pain and reflexes...write them all.
01-31-2009, 05:39 PM
can any one explain that:
I failed ICE I don't know why here is the report Data Gathering xxxxxxxxxxxxxxxxx Patient Note * can any one tell me what * means and why there is no xxx next to it. did any one had the same report and passed? does recheck helps? thank you. |
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