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History and Physical Admit Orders Advice Help Tips Secrets
Print Below is an explanation of how to do an H&P with an assessment and plan guide. CC: When you are doing your H&P for inpatient medicine, this should be their admitting diagnosis and should answer...
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Free Patient Tracker Sheets
Free Patient Medical Tracking Forms For Students: New Patient Admit Sheet- use this sheet to get pertinent information about new patients. Also formatted i...
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How to do a Admit Transfer Orders
Admit and Transfer orders DIAGNOSIS: list in order of priority. CONDITION: good, stable, fair, guarded, critical, etc. DO NOT PUT CONDITION AS STABLE! Use "Fair". If they are stable, send them home! V...
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How to do a Consult Advice Help Tips Secrets
Print Below is an explanation of how to do a Consult. A consult differs slightly from an H&P. A consultant is usually asked to see a patient for a specific reason and for a problem that the primary ph...
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Post Operative Note
Post Operative Note PROCEDURE: surgery performed. S: patient comments or complaints, nursing comments, CHECK consciousness (alert, oriented, drowsy), pain control, passed gas, urine? Bowel movements, ...
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Progress SOAP Note
Progress SOAP Note O: VITALS: blood pressure, pulse, respirations, temp, weight, O2 sat. INS/OUTS: IV fluid, PO intake, emesis, urine, stool, drains. EXAM: physical findings. LABS: new laboratory or p...