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Example Notes

Chapter 2

TermDefinition
Clinical Note When a patient goes to an office setting this note is written up.
Consult Note: What are the 2 different versions? Note from visit to specialist or consultant. Most common- Similar to clinic note. 2nd- Letter format
Emergency Department Note: What is different about this note? Used when seen in emergency department or urgent care clinics. A. Emergency department course- explains what happened to patient during stay. Mixture of completed tests, patient assessments, and plan for patient that unfolds over time.
Admission Summary: What part does this note focus on? What is different about this note? Upon admittance to hospital this note is made. A. Focuses on Subjective and Objective A. Assessment and plan portion will be placed together.
Discharge Summary: What is different about this note? Details when and why patient was admitted and similar to ED note BUT these documents a longer stay in the hospital. A. Breaks from SOAP pattern - Leads with diagnosis.
Operative Note: Why is this similar to the discharge summary? This note is written after every sugery. A. Starts with the disgnosis
Daily Hospital Note/Progress Note: Why is this different? Used to document visit at hospital. A. Assessment and plan are together.
Radiology Report Explains reason for ordering radiologic image. Usually, a recommendation for a different type of imaging.
Pathology Report Mentions reason for study
Prescription: What is the order of the note? 1st line: Name and strength of medicine. 2nd line: Patients instructions. 3rd line: How much medicine to give. 4th line: How many refills. 5th line: Signature
Created by: JenHope
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