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Jul 12, 2022 · It is the responsibility of the organized medical staff to determine the minimum required content of medical history and physical (H & P) examinations (see MS.03.01.01 EP 6). The required content is relevant and includes sufficient information necessary to provide the care, treatment and services required addressing the patient's condition ...
For each diagnosis discuss physiologic disease basis relevant to the patient and elements from the patient’s history and physical that either support or refute the diagnosis. For each item on your differential, explain what makes it likely AND what makes it less likely.
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- Key Information
- Pelvic Examination
- Visual Examination
- Visual Field Examination
Masses and enlarged organs (organomegaly; hepatomegaly; splenomegaly); palpable lymph nodes; jaundice (yellowing of skin and eyes due to blockage of bileducts).
Manual or speculum evaluation of cervix, vagina, rectum, externalgenitalia. Digital examination of the rectum and vagina is also called a rectovaginal exam.
Visualization of clinically accessible areas of the head and neckby viewing them in a mirror or through an endoscope (see also Endoscopies).
A test to determine any defects in the patient's vision, which in turn may reveal the location of a brain tumor. Visual field alterations caused by problems in different brainsites are unique.
The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and. date and legible identity of the observer.
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Apr 3, 2015 · Test results plus findings from the history and physical examination may confirm or refute the main and differential diagnoses, setting up either a management plan or the need for an alternative hypothesis.
- J. Lucian Davis, John F. Murray
- 10.1016/B978-1-4557-3383-5.00016-6
- 2016
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Aug 26, 2024 · The H&P: History and Physical is the most formal and complete assessment of the patient and the problem. H&P is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.
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May 14, 2013 · For accuracy of coding, list all current diagnoses. If a diagnosis is listed but is no longer present or no longer being treated, document that it was resolved prior to admission. Include documentation of the etiology, severity and acuity of the diagnosis (es), if known.
