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The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
H&P: history and physical examination (which very often are considered as a pair) HPA: hypothalamic-pituitary-adrenal axis: HPETE: hydroxyeicosatetraenoic acid: HPF: high-power field HPI H/oPI: history of the present illness: HPOA: hypertrophic pulmonary osteoarthropathy hPL: human placental lactogen (same as human chorionic somatomammotropin) HPP
Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care.
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
IPPA. Inspection of scars or skin changes; Palpation of temporomandibular joint, thyroid, and lymph nodes; Percussion may involve the skin above the frontal sinuses and paranasal sinuses to detect any signs of pain
Different sources include different questions to be asked while conducting an HPI. Several acronyms have been developed to categorize the appropriate questions to include.
The Dextroscope is a medical equipment system that creates a virtual reality (VR) environment in which surgeons can plan neurosurgical and other surgical procedures. [1]The Dextroscope is designed to show a patient's 3D anatomical relationships and pathology in great detail.