Carefully examine the examples of chart notes that have been illustrated and retype the following information as office chart notes for your employer
I don’t have to write the review test on a separate piece of paper. I have to type it in word. How do I makes chart in word or do I use something else?
After you 1 1-3 REVIEW TEST DIRECTIONS: Carefully examine the examples of chart notes that have been illustrated and retype the following information as office chart notes for your employer, Laurel R. Denison, MD. You can use the minimum chart note heading, plain (unlined) 81/2 x 11 inch paper, format of your choice, and standard abbreviations where applicable Use today’s date. Please notice that these are notes about several patients; therefore, each patient should have a separate sheet of paper. Runups 1. Gustavo de Vargas. Birthdate 3-3-34. Patient had onset of persistent vomiting five days ago. He does not appear seriously ill. The abdomen remains flat and there is no tenderness or rigidity; no masses are palpable; bowel sounds are scarce. X-ray of the abdomen yesterday revealed a four centimeter, ill-defined, round mass in the right upper quadrant and loops of small bowel containing air. Subsequent x-rays, including some taken today, revealed that this rounded mass persists, is quite well outlined on some of the x-rays, and is now in the left lower quadrant. There is small bowel distention in relation to the mass, which suggests that the mass is a loop of small bowel with gaseous distention proximal to it. It is questionable whether there is any gas in the colon. Rectal examination is negative. Impression: intestinal obstruction due to ingested foreign body. Advice: laparotomy. 2. Mrs Esther Conway. Age thirty-three. Patient complains of constant dribbling, wetting at night, uses fifteen pads a day. Urinalysis: specific gravity one point zero, few bacteria, few urates. Diagnosis: urinary incontinence. Patient is to return in four days for diagnostic testing. 3. Robin Vincenti. Age twenty-seven. Patient complains of having had the flu and headache and of being tired. Unable to go to work today. Exam shows weakness of left hand. Hyperreflexia on the left. X-ray shows cardiomegaly and slight pulmonary congestion. Impression: post flu syndrome, transient ischemic attack; possible CVA. Patient to return in four days and may return to work in approximately one week. 4. Marissa Weeks. Age seventeen. CC: thrown from a horse. Px: numerous contusions, tenderness in thoracic region, x-ray ordered. Dx: compression fracture of "tee twelve." Rx: patient referred to Edward Harrison, orthopedic specialist. 5. William Santee. Age thirteen. (Make your entry showing a letter was dictated rather than a chart entry made [see Figure 6-1, pp. 150-153, for the actual letter that was dictated and transcribed]. You do not type this letter; you prepare a chart note in reference to this letter. Use February 7 as your date rather than today’s date.
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