ER ADMMISION‚ HISTORY AND PHYSICAL EXAMINATION Admitting/ Attending Physician: Alex McClure M.D. Patient name: Benjamin Engel Hart Patient ID: 112592 DOB: 10/5 Age: 46 Sex: Male Date of admission: 11/14/---- Emergency room physician: Alex McClure M.D. Admitting diagnosis: Acute appendicitis. History of present illness: This 46 year old gentlemen with past medical history significant only for the generative disease of bi-lateral hips‚ secondary arthritis presents
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death‚ human error is also unavoidable. When these two unavoidable factors come together in a medical institution where salvation is expected‚ the result is tragedy. Needlessly‚ thousands of lives have been lost due to simple human mistakes in the very place where the best chance of saving those lives could be found. Despite the expense and hurdles of implementation‚ the establishment of an Electronic Medical Record (EMR) infrastructure is an essential key to saving lives and money over the long term
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HISTORY AND PHYSICAL EXAMINATION OR EMERGANCY DEPARTMENT TREATMENT RECORD Patient Name : Benjamin Engelhart Patient ID : 112592 Date of Birth : 10/05/1958 Age : 46 Sex : Male Date of Admission : 11/14/2014 Emergency Room Physician : Alex McClure‚ MD Admitting Diagnosis : Acute Appendicitis. HISTORY OF PRESENT ILLNESS: This 46-year-old gentle man‚ with past medical history‚ significant only fo r degenerative disease of the bilateral hips‚ seconda ry to arthritis‚
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about cannabis in recent history‚ the truths are slowly starting to resurface. Unfortunately‚ these truths are under heavy criticism due to the stereotypical view of what people view as the typical “pot smoker.” This skewed perception of a lazy and unmotivated American is the result of over seventy years of propaganda and misinformation spread by private interests who relied on illegal cannabis illegal from their own personal gains. As a marijuana consumer and a current medical marijuana patient‚ I strongly
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Dermatology Chart Note 1 Yanktonai‚ Lakota # 765851 May 2‚ 2015 SUBJECTIVE Patient is a 9 year old adolescent male‚ presents with a 2 day history of itching encrusted sores especially around the mouth area. Parent is using OTC antibiotic ointment with no improvement‚ no recent history of fever. Parent states that pat recently visited a petting zoo OBJECTIVE HEENT are basically unrevealing. Temp in the office today is 98.4. The outer area of the mouth extending into the chin reveals macules‚
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Station 1: History Taking 1. Preliminaries Self-introduction: full name __ year medical student from Monash University Explain what you are going to do: take medical history will involve asking some questions about your current illness‚ past illness‚ lifestyle etc. all information obtained will be kept confidential and only be revealed to the GP Obtain consent Obtain patient’s biodata: Full name Age Occupation Marital status 2. History of Presenting Complaint – WWQQAA + B + ICE
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Health Assessment Professor Ava Farahany January 14‚ 2011 Journal Article Review #1 “A guide to taking a patient’s history” is an article found in the December 2007 issue of the Nursing Standard which was written by‚ Hilary Lloyd and Stephen Craig. In this article Lloyd and Craig create an outline of sorts that can be followed in order to obtain a more thorough patient history. Throughout the article‚ Lloyd and Craig take us through this outline which includes topics such as preparation of the
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on the medical‚ psychosocial and functional capabilities and limitations of elderly patients. Various geriatric practitioners use the information generated to develop treatment and long-term follow-up plans‚ arrange for primary care and rehabilitative services‚ organize and facilitate the intricate process of case management‚ determine long-term care requirements and optimal placement‚ and make the best use of health care resources. The geriatric assessment differs from a standard medical evaluation
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the duration of time the problem has existed. The chief complaint is the signs and symptoms causing the patient to seek medical attention. Generally‚ it is the answer to the question‚ "What brought you into the hospital (or clinic) today?" If a well person is seeking a routine physical‚ there is no actual chief complaint Another component of assessment is the past medical history. This provides background for understanding the patient as a whole and his present illness. It includes childhood illnesses
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ELECTONIC MEDICAL RECORDS Katie Percival Northeast Technical Institute February 15‚ 2013 Principles of Health Information Many doctors and hospitals are now using electronic medical records systems. Slowly‚ old files with long background histories are being uploaded via electronic means. At the same time‚ technology has made it possible to keep these files safe from damages or being lost. Computer programs designed for backup have become available. More and more features are being added to
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