Medical Record Documentation of Seizures

1992 ◽  
Vol 13 (2) ◽  
pp. 76-77
Keyword(s):  
Medical Record ◽  
Chief Complaint ◽  
Total Loss ◽  
Loss Of Consciousness ◽  
Pertinent Data ◽  
Sample Record ◽  
Medical Record Documentation

This sample record is meant to demonstrate comprehensive recording of pertinent data. Actual records will vary in format; many will be written in a more abbreviated style. Name: Sharon DiStefano1 Date of birth: December 8, 19832 Drug allergies: None; cramps from erythromycin3 Immunizations: Fully immunized4 Thursday, February 6, 1992 Telephone Teacher called parents — Sharon "suddenly gets a blank look" for brief periods. Has done this several times. Parents will get further information from teacher, watch carefully over weekend, bring in for visit next week. Tuesday, February 11, 1992 CHIEF COMPLAINT: "We think she's having spells." PRESENT ILLNESS: (See letter from teacher). He has noted over the last week, on 5 or 6 occasions, that Sharon will develop "blank stare" suddenly. When talked to, will not respond at first but will after several repetitions. Once did this in the middle of talking; paused noticeably for a number of seconds, then resumed talking. Eyes always stay open; blinking noted; no total loss of consciousness. No jerking, twitching, slumping, drooling, incontinence. Seems normal afterwards; not aware of any lapse. Over the weekend parents saw similar spells: three times at meals, twice when watching television, once after she had been running around backyard and had just sat down. "Like a shade was drawn behind her eyes."

MEDICAL RECORD DOCUMENTATION OF ACUTE PHARYNGITIS

1990 ◽  
Vol 12 (5) ◽  
pp. 134-135
Keyword(s):  
Lymph Node ◽  
Physical Examination ◽  
Medical Record ◽  
Sore Throat ◽  
Soft Palate ◽  
Chief Complaint ◽  
Birth Date ◽  
Mandibular Angle ◽  
Acute Pharyngitis ◽  
Medical Record Documentation

Name: Charles Whitcomb1 Birth date: May 3, 19762 Drug allergies: Hives with sulfonamides3 Immunizations: 5 DTP injections recorded4 Monday, September 24, 1990 CHIEF COMPLAINT: Sore throat. HISTORY: Throat started to hurt late Friday and has worsened gradually over the weekend. Hurts to swallow. Took temperature once: 100°F last night. Nose stuffy. Thinks he has swollen glands. PHYSICAL EXAMINATION: Fairly comfortable; complaining of throat pain. Temperature: 101°F orally. Tympanic membranes: clear. Nose: No discharge but sounds stuffy. Pharynx: Small tonsils; mildly erythematous; no exudate. Posterior soft palate and uvula mildly swollen; no petechiae. Neck: 1.0 cm mildly tender lymph node at each mandibular angle. A few smaller anterior and a number of 0.5 cm posterior cervical nodes. Neck fully supple.

Medical Record Documentation of Chronic Abdominal Pain

1993 ◽  
Vol 14 (2) ◽  
pp. 68-69
Author(s):  
H. Shah
Keyword(s):  
Abdominal Pain ◽  
Medical Record ◽  
School Nurse ◽  
Chronic Abdominal Pain ◽  
Chief Complaint ◽  
School Absence ◽  
Bowel Movements ◽  
Long Time ◽  
Obvious Relation ◽  
Medical Record Documentation

Name: Martha McCue1 Date of birth: June 24, 19842 Drug allergies: None known3 Immunizations: Complete4 Thursday, December 3, 1992 CHIEF COMPLAINT: "She's been having stomach aches since summer." PRESENT ILLNESS: (without prospective diary) Stomach hurting off and on since end of summer. May have started on vacation. Says stomach hurts "lots of days." Many times too uncomfortable to go to school or mother has to get her. School nurse worried there is something wrong. Pain is usually "in middle." No obvious relation to meals; "can happen anytime." Not sure if it wakes her up, "but sometimes I have bad dreams." Pain lasts "a long time." Appetite normal for her; picky eater. No obvious relation to specific foods. Thinks bowel movements are normal; can't remember how often. No discomfort urinating. Has not had temperature taken. Remembers vomiting once. Mother thinks one bout was related to taking antibiotic. PRESENT ILLNESS: (with prospective diary) Father had vomiting and diarrhea mid-August on vacation; better in 4 days. Martha caught it and had pronounced cramps. Not a week without abdominal pain since then. Several bouts a week. Diary shows pronounced pain on Sunday evenings, Monday mornings, Tuesday mornings, causing school absence 3 days. Milder discomfort on other days. No pain over Thanksgiving vacation until Sunday night.

scholarly journals "Concordance between comorbidity data from patient self-report interviews and medical record documentation"

2008 ◽  
Vol 8 (1) ◽  
Author(s):  
William Corser ◽  
Alla Sikorskii ◽  
Ade Olomu ◽  
Manfred Stommel ◽  
Camille Proden ◽  
...  
Keyword(s):  
Medical Record ◽  
Self Report ◽  
Medical Record Documentation

Medical Record Documentation of Head Injury

1993 ◽  
Vol 14 (8) ◽  
pp. 300-301
Keyword(s):  
Blood Pressure ◽  
Head Injury ◽  
Chief Complaint ◽  
Problem List ◽  
Past Medical History ◽  
Retinal Hemorrhages ◽  
Parietal Area ◽  
Regular Rhythm ◽  
Optic Discs ◽  
Medical Record Documentation

Name: Roger Horton1 Date of Birth: June 1, 19842 Drug Allergies: None known3 Immunizations: Complete4 Wednesday, June 9, 1993 1 PM CHIEF COMPLAINT: Fell and hit side and head. PRESENT ILLNESS: At 12:15 PM was swinging high on swing at schoolyard. Fell off at top of arc and landed on hard ground, striking right side of body and right side of head. Remembers landing and "seeing stars," then being surrounded by others. Does not think he lost consciousness. Walked into school, with help. PAST MEDICAL HISTORY (as recorded on problem list): Occasional wheezing, relieved by albuterol inhaler. Fracture, left radius, age 6. PHYSICAL EXAMINATION: Slim, pale boy, sitting quietly on table. Complains of headache; feels "sick to my stomach" and cold. Right shoulder and hip hurt; neck does not. Weight: 58 lb Temperature: 98.2°F, orally Pulse rate: 92 beats/min Respiratory rate: 20 breaths/min Blood pressure: 120/70 Head: Tender and mildly swollen over right parietal area. Eyes: Sclerae clear. Pupils equal in size and reactive. Extraocular movements full without nystagmus. Media clear. Optic discs sharp. Venous pulsations noted. No retinal hemorrhages. Acuity 20/26 in each eye. Ears: Clear tympanic membranes without blood. Nose: Clear; no discharge. Mouth/throat: Clear; no injury noted. Neck: Full movement without pain. Mild tenderness on right side. Chest: Breathing easily. Clear sounds. No tenderness of ribs. Heart: Good sounds in regular rhythm without murmurs.

Sa1046 Improving Medical Record Documentation of Clinical Encounters in Inflammatory Bowel Disease (IBD) Patients: A Review of Current Practice

2015 ◽  
Vol 148 (4) ◽  
pp. S-206
Author(s):  
Ashraf A. Almashhrawi ◽  
Fazia A. Mir ◽  
Amin Mahdi ◽  
Anjana Sathyamurthy ◽  
Richard Madsen ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Medical Record ◽  
Bowel Disease ◽  
Current Practice ◽  
Clinical Encounters ◽  
Inflammatory Bowel ◽  
Medical Record Documentation

scholarly journals A pilot study of the impact of an educational intervention aimed at improving medical record documentation

2013 ◽  
Vol 43 (1) ◽  
pp. 29-34 ◽  
Author(s):  
M Farzandipour ◽  
Z Meidani ◽  
F Rangraz Jeddi ◽  
H Gilasi ◽  
L Shokrizadeh Arani ◽  
...  
Keyword(s):  
Pilot Study ◽  
Medical Record ◽  
Educational Intervention ◽  
The Impact ◽  
Medical Record Documentation

scholarly journals QUANTITATIVE EVALUATION OF MEDICAL RECORD DOCUMENTATION IN IMAM REZA HOSPITAL, MASHHAD, IRAN

2017 ◽  
Vol 1 (4) ◽  
pp. 98-99
Author(s):  
Zahra Mazloum khorasani ◽  
Mahmood Tara ◽  
Kobra Etminani ◽  
Zohre Moosavi ◽  
Zahra Ebnehoseini
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Qualitative Evaluation ◽  
Cross Sectional Study ◽  
Diabetic Patients ◽  
Cross Sectional ◽  
Accurate Treatment ◽  
Diabetes Center ◽  
Data Elements ◽  
Medical Record Documentation

Introduction: Diabetes is the most common endocrine disease. Given the importance of medical record documentation for diabetic patients and its significant impact on accurate treatment process, as well as early diagnosis and treatment of acute and chronic complications, this study aimed to qualitatively evaluate medical record documentation of diabetic patients. Methods: This descriptive and cross-sectional study was conducted on all medical records of diabetic patients (1200 cases) in the comprehensive Diabetes Center of Imam Reza Hospital. A checklist was prepared according to the main sectors and their sub-data elements to conduct a qualitative evaluation on documentation of medical records of diabetic patients.  Descriptive statistics were used to report the results. Results: In this study, 1200 (710 women and 490 men) cases were evaluated. Mean documentation of main sectors of diabetic patients’ records were as follows: 49% demographic characteristics, 14% patient referral, 4% diagnosis, 50% lab tests, 25% diabetes medications,13% nephropathy screening test, 10% diabetic neuropathy, 41% specialty and subspecialty consultations and internal medicine physicians visits did not complete for all the patients. Conclusion: According to the results of this study, qualitative evaluation of medical record documentation of diabetic patients Showed poor documentation in this regard. It is suggested that results of this study be accessible to physicians of healthcare centers to take a positive step toward improved documentation of medical records. In addition, it seems necessary to modify diabetic medical records.

scholarly journals Understanding Factors Contributing to Inappropriate Critical Care: A Mixed-Methods Analysis of Medical Record Documentation

2017 ◽  
Vol 20 (11) ◽  
pp. 1260-1266 ◽  
Author(s):  
Thanh H. Neville ◽  
Derjung M. Tarn ◽  
Myrtle Yamamoto ◽  
Bryan J. Garber ◽  
Neil S. Wenger
Keyword(s):  
Critical Care ◽  
Mixed Methods ◽  
Medical Record ◽  
Medical Record Documentation

MEDICAL RECORD DOCUMENTATION OF ACUTE GASTROENTERITIS

1991 ◽  
Vol 12 (12) ◽  
pp. 374-374
Keyword(s):  
Medical Record ◽  
Electrolyte Solution ◽  
Acute Gastroenteritis ◽  
Birth Date ◽  
Loose Stool ◽  
Late Afternoon ◽  
Full Strength ◽  
Medical Record Documentation

Name: Matthew Pringle1 Birth date: July 15, 19902 Drug allergies: None known3 Thursday, February 14, 1991. Telephone 11:00 AM. Matt vomited x2 since getting up—1 loose stool. Alert, wet diapers twice today. No fever. Mom to give 1-2 oz of commercial maintenance electrolyte solution (40-50 mEq/L of sodium) every 20-30 min. Call back late afternoon. W.R., MD 4:00 PM. No more vomiting. Kept 12 oz of electrolyte solution. Very wet diaper now. 1 loose stool. Regularly on soy formula. Mom to give 2-3 bottles of diluted soy, then full-strength. Call tomorrow morning—sooner if diarrhea worsens, has repeated vomiting, or starts to look sicker. W.R., MD

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