Question

MEDICAL DOCUMENTS: TYPES AND FORMATS Carefully look over the documentation. In the blank space at the right, retype each heading/sentence putting it in the proper format and correcting all errors. 1 DIAGNOSIS Urinary tract infection ADMITTING DIAGNOSIS 1 Hypertensicn uncontrolled 2 Extreme fatigue PREOPERATIVE DIAGNOSIS 4 POSTOPERATIVE DIAGNOSIS Same DIAGNOSES Coronary artery disease 6 OPERATION CABG None Allergic to codeine 2. Extreme fatigue

Answer 1

1. Assessment: This forms the first step when a patient visits a health care professional
2. Impression : This is formed as a result of assessment and the summary of clinical findings (sinusitis, extreme fatigue)
3. Allergies :This is a part of history collection (food or drug)here the patient is allergic to codeine
4. Admitting diagnosis :formed after assessment and before confirmation of the actual diagnosis and the one the patient has previously (hypertension uncontrolled, extreme fatigue )
5. Diagnosis :The actual diagnosis of the illness (Urinary tract infections#1 )
6. Pre operative diagnosis :before surgical intervention of medical illness (urolithiasis)
7. Diagnosis :Coronary artery disease (#2)
8. Operation : the most important procedure to save this patient is a surgical intervention (CABG)
9. Postoperative diagnosis :will be same (coronary artery disease )
10. Complication: It is the end results of any treatment (here the patient has no complications )