patient note - abdullahk85

[ArchivalUser]

can somebody help me with a sample patient note ? tnks.....

[ArchivalUser]

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, //

[ArchivalUser]

SHx; EX SMOKER*3 (1PPD*25 YRS)
It means pt has quit smoking Since 3 years and has been smoker for 25 years 1PPD

[ArchivalUser]

is there any advise to improve patient note

[ArchivalUser]

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.

[ArchivalUser]

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.