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Assessment: Dry skin (s/l ictiosis).

Posted By: Just Looking on 2008-09-04
In Reply to:

Subject: Assessment: Dry skin (s/l ictiosis).

:-)


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Assessment
Subject: Assessment

 


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Anyone have any idea what this is?? I'm drawing a blank.


TY!!


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Can you have an abbreviation like URI in an assessment? Thx. Tina

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Thank you for the assessment info!!
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Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan

1.      Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago.  I asked him to repeat it, but he forgot.  We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly.  He is not symptomatic.


 


I keep listening over and over to this, and this is all I can make out.  Any clue what he might be referring to??? TIA


It was not a test. It was the assessment.
Subject: It was not a test. It was the assessment.

nm
assessment&plan help!
Subject: assessment&plan help!

If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?


 


ASSESSMENT:



  1. Bilaterally arm numbness.
  2. Nausea.
  3. Health maintenance recommendations.

 


PLAN:



  1. Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion.  She will be referred for MRI with cervical spine.  Patient may need EMG to further access her numbness.
  2. Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn.  She does have chronic nausea and this may be a sign of stomach reflux.  She will be tried on Nexium 40 mg one q.d.  Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night.  We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism.  ___ problem health maintenance and in regards to increase her exercise and changing her diet.  Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram.  When she follows up to see me we will discuss potential options for colon screening.  Patient is to follow-up with me in approximately 1 month time. 

assessment and plan
Subject: assessment and plan

I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
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Or is it noncompelling?


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 Hi!  Need help as soon as possible.  Typing history and physical for admission of a woman in labor.  Here is what is dicated:


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