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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 ...
In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms.
Stratosphere sign is a clinical medical ultrasound finding usually in an eFAST examination that can prove presence of a pneumothorax. The sign is an imaging finding using a 3.5–7.5 MHz ultrasound probe in the fourth and fifth intercostal spaces in the anterior clavicular line using the M-Mode of the machine. This finding is seen in the M-mode ...
For example, in gastrectomy, ... such as arthroscopic or laparoscopic surgery. These take the same form as above; an arthroscope is a device which allows the inside ...
The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. [1] The checklist serves to remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained instruments. [1]
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).
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An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.