Reexamination sample documentation

Background

• Failure to document a reassessment is a common medicolegal vulnerability
• The reassessment should include interval changes in symptoms, vitals, and exam findings
• Document response to treatment and clinical trajectory (improving, unchanged, worsening)
• Reassessment documentation frequently supports the disposition decision (safe to discharge vs. need for admission)

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. Patient 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

Patient 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.

See Also

Documentation Pages

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations