Diferencia entre revisiones de «Reexamination sample documentation»
Sin resumen de edición |
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| Línea 2: | Línea 2: | ||
===Improved=== | ===Improved=== | ||
Rexamination Before Discharge | Rexamination Before Discharge | ||
Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. Patient feels much better and can tolerate POs. | Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. Patient feels much better and can tolerate POs. Patient is aware of and understands precautions, as well as need to follow up. | ||
===Resolved=== | ===Resolved=== | ||
Rexamination Before Discharge | Rexamination Before Discharge | ||
Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. | Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. Patient feels much better with full resolutions of symptoms and would like to go home. @NAME@ can tolerate POs and, after a long discussion, is aware of and understands precautions as well as need to follow up. | ||
==Admit improved== | ==Admit improved== | ||
| Línea 18: | Línea 18: | ||
==General discharge improved== | ==General discharge improved== | ||
Rexamination Before Discharge | Rexamination Before Discharge | ||
Before discharge | Before discharge patient was feeling much better with improving of symptoms, and would like to go home. Tolerating POs. | ||
==General resolved== | ==General resolved== | ||
Rexamination Before Discharge | Rexamination Before Discharge | ||
Before discharge | Before discharge patient was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs. | ||
==Reexam trauma== | ==Reexam trauma== | ||
Rexamination Before Discharge | Rexamination Before Discharge | ||
A full tertiary reexam showed | A full tertiary reexam showed patient to be feeling much better with improvement of symptoms. No additional injuries were noted and patient no change in neurologic and vascular function. Compartments are soft. | ||
==Reexam wheeze== | ==Reexam wheeze== | ||
Rexamination Before Discharge | Rexamination Before Discharge | ||
Before discharge | Before discharge patient had clear lung sounds bilaterally without evidence of respiratory distress, and feels much better. Would not like any further treatments and would like to go home. | ||
==See Also== | ==See Also== | ||
Revisión del 17:37 27 jul 2022
Abdominal exam
Improved
Rexamination Before Discharge Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. Patient feels much better and can tolerate POs. Patient is aware of and understands precautions, as well as need to follow up.
Resolved
Rexamination Before Discharge Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. Patient feels much better with full resolutions of symptoms and would like to go home. @NAME@ can tolerate POs and, after a long discussion, is aware of and understands precautions as well as need to follow up.
Admit improved
Rexamination Before Admission @NAME@ had significant improvement with symptoms/vitals. Improving with treatment.
ETOH discharge
Rexamination Before Discharge Before discharge patient was feeling much better with resolution of symptoms, and would like to go home. Tolerating POs. Has a steady gait and non-slurred speech. No tremor. Patient acknowledges that will not drive, operate heavy machinery, etc. while intoxicated. Has a reasonable plan for self care. No SI/HI.
General discharge improved
Rexamination Before Discharge Before discharge patient was feeling much better with improving of symptoms, and would like to go home. Tolerating POs.
General resolved
Rexamination Before Discharge Before discharge patient was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs.
Reexam trauma
Rexamination Before Discharge A full tertiary reexam showed patient to be feeling much better with improvement of symptoms. No additional injuries were noted and patient no change in neurologic and vascular function. Compartments are soft.
Reexam wheeze
Rexamination Before Discharge Before discharge patient had clear lung sounds bilaterally without evidence of respiratory distress, and feels much better. Would not like any further treatments and would like to go home.