Reexamination sample documentation - Revision history

Rossdonaldson1: /* See Also */

2026-03-25T17:53:54Z

Rossdonaldson1: /* See Also */

2026-03-25T17:53:40Z

Rossdonaldson1: /* Background */

2026-03-25T17:53:25Z

Background

← Older revision		Revision as of 17:53, 25 March 2026
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	==Background==		==Background==
	*Reassessment documentation demonstrates that the patient was re-evaluated prior to disposition
	*Failure to document a reassessment is a common medicolegal vulnerability<ref>Selbst SM. The difficult-to-manage patient in the emergency department. Int J Emerg Med. 2009;2(2):103-107.</ref>		*Failure to document a reassessment is a common medicolegal vulnerability<ref>Selbst SM. The difficult-to-manage patient in the emergency department. Int J Emerg Med. 2009;2(2):103-107.</ref>
	*The reassessment should include interval changes in symptoms, vitals, and exam findings		*The reassessment should include interval changes in symptoms, vitals, and exam findings
	*Document response to treatment and clinical trajectory (improving, unchanged, worsening)		*Document response to treatment and clinical trajectory (improving, unchanged, worsening)
	*Reassessment documentation supports the disposition decision (safe to discharge vs. need for admission)		*Reassessment documentation frequently supports the disposition decision (safe to discharge vs. need for admission)

	==Abdominal exam==		==Abdominal exam==

Rossdonaldson1: /* Background */

2026-03-25T17:52:42Z

Background

← Older revision		Revision as of 17:52, 25 March 2026
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	*Reassessment documentation demonstrates that the patient was re-evaluated prior to disposition		*Reassessment documentation demonstrates that the patient was re-evaluated prior to disposition
	*Failure to document a reassessment is a common medicolegal vulnerability<ref>Selbst SM. The difficult-to-manage patient in the emergency department. Int J Emerg Med. 2009;2(2):103-107.</ref>		*Failure to document a reassessment is a common medicolegal vulnerability<ref>Selbst SM. The difficult-to-manage patient in the emergency department. Int J Emerg Med. 2009;2(2):103-107.</ref>
	*The reassessment should include ~~'''~~interval changes~~'''~~ in symptoms, vitals, and exam findings		*The reassessment should include interval changes in symptoms, vitals, and exam findings
	*Document ~~'''~~response to treatment~~'''~~ and ~~'''~~clinical trajectory~~'''~~ (improving, unchanged, worsening)		*Document response to treatment and clinical trajectory (improving, unchanged, worsening)
	*Reassessment documentation supports the disposition decision (safe to discharge vs. need for admission)		*Reassessment documentation supports the disposition decision (safe to discharge vs. need for admission)

Danbot: Added Background section with reference, expanded See Also, documentation pages template

2026-03-24T11:05:55Z

Added Background section with reference, expanded See Also, documentation pages template

@@ Line 1: / Line 1: @@
 ==Abdominal exam==
 ===Improved===
@@ Line 34: / Line 41: @@
 ==See Also==
 *[[Documentation for emergency physicians]]
 [[Category:Documentation]]

Rossdonaldson1 at 17:39, 27 July 2022

2022-07-27T17:39:31Z

Rossdonaldson1 at 17:38, 27 July 2022

2022-07-27T17:38:20Z

← Older revision		Revision as of 17:38, 27 July 2022
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	==Abdominal exam==		==Abdominal exam==
	===Improved===		===Improved===
	~~Rexamination~~ Before Discharge		Reexamination 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.		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		Reexamination 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.		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==
	~~Rexamination~~ Before Admission		Reexamination Before Admission
	@NAME@ had significant improvement with symptoms/vitals. Improving with treatment.		@NAME@ had significant improvement with symptoms/vitals. Improving with treatment.

	==ETOH discharge==		==ETOH discharge==
	~~Rexamination~~ Before Discharge		Reexamination 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.		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==		==General discharge improved==
	~~Rexamination~~ Before Discharge		Reexamination Before Discharge
	Before discharge patient was feeling much better with improving of symptoms, and would like to go home. Tolerating POs.		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		Reexamination Before Discharge
	Before discharge patient was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs.		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		Reexamination 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.		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		Reexamination 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.		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.

Rossdonaldson1 at 17:37, 27 July 2022

2022-07-27T17:37:46Z

← Older revision		Revision as of 17:37, 27 July 2022
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	===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. ~~@NAME@~~ is aware of and understands precautions, as well as need to follow up.		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. ~~@NAME@~~ 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.		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==
Line 18:		Line 18:
	==General discharge improved==		==General discharge improved==
	Rexamination Before Discharge		Rexamination Before Discharge
	Before discharge ~~@NAME@~~ was feeling much better with ~~improvent~~ of symptoms, and would like to go home. Tolerating POs.		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 ~~@NAME@~~ was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs.		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 ~~@NAME@~~ 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.		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 ~~@NAME@~~ 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.		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==

Rossdonaldson1: /* ETOH discharge */

2022-07-27T16:57:39Z

ETOH discharge

← Older revision		Revision as of 16:57, 27 July 2022
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	==ETOH discharge==		==ETOH discharge==
	Rexamination Before Discharge		Rexamination Before Discharge
	Before discharge ~~@NAME@~~ 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. ~~@NAME@~~ acknowledges that will not drive, operate heavy machinery, etc. while intoxicated. Has a reasonable plan for self care. No SI/HI.		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==		==General discharge improved==

Rossdonaldson1: /* See Also */

2017-04-05T15:07:20Z

← Older revision		Revision as of 17:53, 25 March 2026
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	==See Also==		==See Also==
	*[[Against medical advice]]

	{{Documentation pages}}		{{Documentation pages}}

← Older revision		Revision as of 17:53, 25 March 2026
Line 39:		Line 39:

	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[Physical exam documentation]]
	*[[Discharge documentation]]
	*[[Against medical advice]]		*[[Against medical advice]]

← Older revision		Revision as of 17:39, 27 July 2022
Line 1:		Line 1:
	==Abdominal exam==		==Abdominal exam==
	===Improved===		===Improved===
	Reexamination Before Discharge		:Reexamination 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.		: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===
	Reexamination Before Discharge		:Reexamination 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.		: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. Patient 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==
	Reexamination Before Admission		:Reexamination Before Admission
	~~@NAME@~~ had significant improvement with symptoms/vitals. Improving with treatment.		:Patient had significant improvement with symptoms/vitals. Improving with treatment.

	==ETOH discharge==		==ETOH discharge==
	Reexamination Before Discharge		:Reexamination 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.		: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==		==General discharge improved==
	Reexamination Before Discharge		:Reexamination Before Discharge
	Before discharge patient was feeling much better with improving of symptoms, and would like to go home. Tolerating POs.		:Before discharge patient was feeling much better with improving of symptoms, and would like to go home. Tolerating POs.

	==General resolved==		==General resolved==
	Reexamination Before Discharge		:Reexamination Before Discharge
	Before discharge patient was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs.		:Before discharge patient was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs.

	==Reexam trauma==		==Reexam trauma==
	Reexamination Before Discharge		:Reexamination 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.		: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==
	Reexamination Before Discharge		:Reexamination 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.		: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==

← Older revision		Revision as of 15:07, 5 April 2017
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	==See Also==		==See Also==
	*[[		*[[Documentation for emergency physicians]]

	[[Category:Documentation]]		[[Category:Documentation]]