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4 Cards in this Set
- Front
- Back
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Documentation |
If it wasn't recorded, it wasn't done If any portion of the history or physical exam is deferred, should be noted as such Organize the data into a clear, concise, comprehensive note Do not erase any data entered into medical record, strike through only |
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Subjective |
Include presence and absence of symptoms Significant positives: symptoms that are present, record these first Significant negatives: symptoms that are not present, record after documenting positives Always include presence of constitutional symptoms: fever, chills, sweats, nausea, vomitting, diarrhea, weight loss Use quotes for meaning or significance |
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Objective |
Arrange data in correct sequences Use headings to delineate topics Record subjective info in narrative style, may use terms such as staes, describes, relates, erports, admits to, complains of Use short phrases and avoid long sentences Omit "pt" or "client" Use appropriate medical terminology Cluster and order physical exam Data should be measurable/quantifiable Avoid "normal" or "good" |
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Scale |
Include limits of the scale
Use metric measures or describe physical findings
Avoid judgemental language
Use diagrams when appropriate to clarify and simplify |
