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[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
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.
Tests specific to HEENT examination Eyes: eye examination and acuity (including ophthalmoscope) Ears: hearing examination and evaluation of tympanic membrane (TM) (otoscope used in evaluation of ears, nose, and mouth) A neurological examination is usually considered separate from the HEENT evaluation, although there can be some overlap in some ...
Pages in category "Physical examination" The following 70 pages are in this category, out of 70 total. This list may not reflect recent changes. ...
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. [1]
A pelvic examination is the physical examination of the external and internal female pelvic organs. [1] It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract , such as pain, bleeding, discharge, urinary incontinence , or trauma (e.g. sexual assault).
A shoulder examination (or shoulder exam) is a portion of a physical examination used to identify potential pathology involving the shoulder. It should be conducted with both shoulders exposed to assess for asymmetry and muscle wasting.
An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen.