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A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
A medical certificate or doctor's certificate [1] [2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note (UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition. [4]
Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase such as "no family h/o of heart or lung problems" may be used to specifically indicate that questions about a system were asked. social history (SH) "Denies x3"
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
Where available, ICD-10 codes are listed. When codes are available both as a sign/symptom (R code) and as an underlying condition, the code for the sign is used. When there is no symptoms for a disease that a patient has, the patient is said to be asymptomatic.
Surgery could mean either a lumpectomy (where a portion of the breast tissue is removed along with a very small amount of the healthy surrounding tissue) or a mastectomy (which removes all the ...
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The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. [1] [2]List of ICD-9 codes 001–139: infectious and parasitic diseases