The eight common types of medical reports are the history and physical examination, diagnostic imaging and radiology reports, operative reports, pathology reports, consultations, discharge summary, death summary, and autopsy reports. History and physical examination is done when a patient is admitted into the hospital for evaluations and treatment, the report should include, patient name, patient ID, room number, date of admission/ date of arrival, admitting/attending physician, admitting diagnosis, chief complaint, history of present illness, past history, medications, social history, family history, review of systems, physical examination, diagnostic data, assessment, and physician signature. With diagnostic imaging and radiology reports, radiology is that branch of the health sciences that deals with radioactive substances and radiant energy together with the diagnosis and the treatment of a disease by the means of Roentgen rays or ultrasound techniques. The radiology report is the description of the findings and the interpretations of the radiographs and the other studies that are done by the radiologist. The Radiology/Diagnostic imaging report should include the patient’s name, patient ID, DOB, age, sex, report number, who the ordering physician is, the procedure, date of the procedure, what the primary diagnosis is, the clinical information and physician signature.. Operative reports are done immediately after the completion of a surgical procedure, a record if the procedure must be dictated by the physician, then transcribed and placed in the patient’s files. Preoperative and postoperative diagnoses are included in the report, the body of the report, which includes the findings and procedures, is dictated in a narrative form and it contains information about the patient after the surgery. The operative report should include, the patient name, patient ID, DOB, age, sex, the date of admission, date of procedure, admitting physician, surgeon, assistant, preoperative diagnosis, postoperative diagnosis, operative procedure, anesthesia, specimen removed, IV fluids, estimated blood loss, urine output, complications, a description of procedure, and physician signature. Pathology is the branch of medicine that deals with the study of disease; it is divided into anatomic pathology and clinical pathology. Anatomic pathology is the branch of pathology that tissue reports are issued, the tissue described as both grossly and microscopically by a pathologist. The pathology reports need to include the patient name, ID, DOB, age, sex, pathology report number, date of the surgery, preoperative diagnoses, postoperative diagnoses; specimen submitted, date the specimen was received, date the specimen was reported, clinical history, gross description, microscopic description, microscopic diagnosis, and physician signature. Consults from a physician specializing in different fields of medicine are necessary to provide the proper care for patients, the admitting/attending physician is in charge and maintains continuity of care at all times. The consult reports must include; patient name, ID, DOB, age, sex, room number, consultant, requesting physician, date of consult, reason for consultation, description, treatment plan, goals, and physician signature. Discharge summary is required for each patient who is discharged from the hospital. The discharge report should consist of the patient name, ID, DOB, age, sex, date of admission, date of discharge, admitting physician, consultations, procedure performed, complications, discharge diagnosis, History, diagnostic data on admission, hospital course, discharge diagnoses, discharge medications and the physician
CanGo Week Two Analysis Report DeVry University Bus460 Senior Project Instructor David Mozinski Introduction The Grad Consultants have spent the last two weeks observing CanGo and their business practices to help them determine the weaknesses within their organization. We will use our knowledge and experience to provide suggestions for improvement that will have a positive impact not only on CanGo’s bottom line but also on the morale of all those…
oleic acid, has been shown to significantly decrease you LDL cholesterol (bad kind) while promoting the HDL cholesterol (bad kind). Salmon – high in Vitamin D, omega-3 fatty acids. Vitamin D protects the immune system and fights off infection. 2. How does the food pyramid work here? Is this a good tool or have you discovered another? How will you measure success? Take a manufactured food and read the label. What are the ingredients? Why would this not be a superfood? The four basic super foods…
Week 1 & 2 Analysis Report “Poor strategic planning is worse than no strategic planning. It can be a big waste of time and money” (“Strategic Thinking”, 2011, p.1). Strategic planning plays a very crucial role in helping organizations achieve their goals. The strategic planning process requires both managers and their subordinates to work together as a team to design, plan and implement those goals. We have noticed that there have been some deficiencies in the leadership of CanGo Inc. We…
Week Term 1 week Term 2 Week 1 Finish planning sheet, question summary sheet and lotus diagram. Start capabilities work sheet and complete task. Finalise detailed sub questions. Week 1 Finish any work not completed (due Friday) Bring in recipes to survey class on opinion on recipes (due Tuesday) Bring in more recipes to survey class on opinion on recipes (due Wednesday) Week 2 Task 1: Proposal draft due Friday week 3 Library orientation for planning research project. Begin draft of proposal…
This pack of COM 155 Week 1 Discussion Questions contains: DQ 1: List at least one of the serious writing errors identified on p. 385 and identify how such an error could negatively affect your writing DQ 2: Identify which of the four most serious writing errors listed on p. 385 you find challenging to overcome in your own writing. State a method to avoid this error. DQ 3: The projects ongoing over the next few days allow one to utilize the grammar lessons covered in the weekly objective list posted…
College. The intern shall complete the reports and documents in the rear of this manual in accordance with the Timeliness Schedule stated herein. The Training Manual shall be given to the TRC Coordinator at the end of the Training Period with all reports and documents completed. The reports and documents shall remain a part of this manual and shall not be removed. The TRC Coordinator shall grade the student based upon intern's satisfactory completion of all reports and documents and Employee's Evaluation…
Module Guide MANAGING STRATEGY AND CHANGE BBM-7-MSC Faculty of Business 2014/2015 MBA (Level 7) Table of Contents 1. Module Details 3 2. Short Description 3 3. Aims of the Module 3 4. Learning Outcomes 3 4.1 Knowledge and Understanding 3 4.2 Intellectual Skills 4 4.3 Practical Skills 4 4.4 Transferable Skills 4 5. Assessment of the Module 4 6. Feedback 5 7. Introduction to Studying the Module 5 7.1 Overview of the Main Content 5 7.2 Overview of Types of Classes 6 7.3 Importance of…
School/Portfolio: The Faculty of Business Course Code/ID: BUMKT1501 Course Title: Introduction to Marketing Teaching Location: Mt Helen Semester: Semester 2 2014 Prerequisite(s): Nil Corequisite(s): Nil Exclusion(s): Nil Credit Points/ Progress Units: 15 ASCED Code: 080505 Adopted Reference Style APA 1 COURSE ORGANISATION: 1.1 Student Responsibility It is the responsibility of every student to be aware of the requirements for this course…
multinational firms. The portfolio will be expanded with derivative products in later weeks of the semester. All portfolio-related transactions will automatically be recorded online. The final investment report can include ONLY transactions that have been recorded online by the system. The TOP THREE ranked groups in terms of profit will be awarded with a BONUS mark of 2% (out of 10%). A printed copy of the investment report is to be submitted to the Faculty’s assignment box on the due date. Submission…