Reexamination sample documentation: Difference between revisions
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==Abdominal exam== | ==Abdominal exam== | ||
===Improved=== | ===Improved=== | ||
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 | |||
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== | ||
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== | ||
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 | |||
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 | |||
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 | |||
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 | |||
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. | ||
Revision as of 17:38, 27 July 2022
Abdominal exam
Improved
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.
Resolved
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.
Admit improved
Reexamination Before Admission @NAME@ had significant improvement with symptoms/vitals. Improving with treatment.
ETOH 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.
General discharge improved
Reexamination Before Discharge Before discharge patient was feeling much better with improving of symptoms, and would like to go home. Tolerating POs.
General resolved
Reexamination Before Discharge Before discharge patient was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs.
Reexam trauma
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.
Reexam wheeze
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.