Review of the patients past history, family history, and social history
Basic emergency care is described as
When a surgical procedure is performed in a clinic, an operative report should be dictated into the medical record
The written record of an autopsy is called the autopsy what?
Findings such as syncope, headache, vertigo, and convulsion would be included in this type of assessment
Listening to body sounds
Medical record notes dated and signed by the doctor
When a surgical procedure is performed to remove tissue or fluid from the body to be examined, the results of the examination probably would appear in what report
A patient with an acute complicated injury has this type of medical decision complexity
An examination of an organ with radioactive isotopes is called a
Verticales
The S in SOAP
Abbreviation of patient information the is used to help the physician in making a diagnosis on which treatment can be used.
This is not a type of medical report
When a patient returns to a hospital within a month of being discharged and has the same complaint, this history may be written
This description section appears first in an autopsy
Listening to the sounds produced when a particular region is tapped
The Diagnostic and Statistical Manual of Mental Disorders is the best resource for looking up words in this type of report
Assessing the patients sense of smell
These reports must be completed within 24 hours
Type of examination that is a limited examination of the affected body area or system and other symptomatic related systems
These reports are often sent to the Social Security Administration
Head, eyes, ears, nose, and throat
The P in SOAP
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