` Medical Record Blunders ◦ Rectal exam revealed a normal size thyroid. (Long fingers?) ◦ Exam of genitalia reveals that he is circus sized. ◦ ◦ On the second day the knee was better and on the third day it had completely disappeared. ◦ ◦ She is numb from her toes down. 1
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` Medical Record Blunders
◦ Rectal exam revealed a normal size thyroid. (Long fingers?)
◦ Exam of genitalia reveals that he is circus sized. ◦ ◦ On the second day the knee was better and on the
third day it had completely disappeared. ◦ ◦ She is numb from her toes down.
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` History and Physical: pp. 41-43 ` Progress Note (SOAP format): pp. 43-44 ` Prescription: pp. 73-76
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` What each form is for. ` What are the component parts of each form. ` What kind of information goes in each
component part. ` The common abbreviations associated with
these forms.
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S: subjective – that which the patient describes O: objective – observable information, such as test results, blood pressure readings, etc. A: assessment – progress and evaluation of the effectiveness of the plan P: plan – decision to proceed or alter strategy
` statim STAT ` pro re nata p.r.n. ` ad libitum ad lib ` noctis (nocte) noc. ` ante meridiem a.m. ` post cibum p.c. ` non/nihil per os NPO ` 1 quaque hora q.1 h, q.1° ` quarter in die (ter…) q.i.d. (t.i.d.)
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` h.s. (hour sleep or half-strength) ` qd and q.o.d (s.i.d. and q.a.d.) ` AD, AS, AU and OS, OD, OU