Diferencia entre revisiones de «Review of systems documentation»

Sin resumen de edición
Sin resumen de edición
 
(No se muestran 2 ediciones intermedias de 2 usuarios)
Línea 1: Línea 1:
REVIEW OF SYSTEMS:
REVIEW OF SYSTEMS:
CONST: [] Negative for fever, body aches and chills.


HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.  
CONST: Negative for fever, body aches and chills.  


EYES:[] Negative for discharge/pain or vision changes.  
HENT: Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.  


RESP:[] Negative for cough/hemoptysis and shortness of breath.
EYES: Negative for discharge/pain or vision changes.  


CV: []Negative chest pain, difficulty breathing,  palpitations.  
RESP: Negative for cough/hemoptysis and shortness of breath.


ABD:[] Negative pain, nausea, vomiting.
CV: Negative chest pain, difficulty breathing, palpitations.  


GU: []Negative increase frequency, dysuria, blood in urine or stool.
ABD: Negative pain, nausea, vomiting.


MUSC: []Negative for muscle aches, edema.  
GU: Negative increase frequency, dysuria, blood in urine or stool.


SKIN: []Negative rash, lesions/sores.
MUSC: Negative for muscle aches, edema.  


NEURO:[] Negative headache, dizziness, weakness.
SKIN: Negative rash, lesions/sores.
 
NEURO: Negative headache, dizziness, weakness.


[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]
[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]
[[Category:Documentation]]

Revisión actual - 22:18 1 dic 2021

REVIEW OF SYSTEMS:

CONST: Negative for fever, body aches and chills.

HENT: Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.

EYES: Negative for discharge/pain or vision changes.

RESP: Negative for cough/hemoptysis and shortness of breath.

CV: Negative chest pain, difficulty breathing, palpitations.

ABD: Negative pain, nausea, vomiting.

GU: Negative increase frequency, dysuria, blood in urine or stool.

MUSC: Negative for muscle aches, edema.

SKIN: Negative rash, lesions/sores.

NEURO: Negative headache, dizziness, weakness.

[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]

Obtenido de «https://www.wikem.org/w/index.php?title=Review_of_systems_documentation&oldid=329927»