What tests did you perform during the visit

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Reference no: EM133819569

Case Study Chosen: (List what case you have chosen) Demographics: Age/Gender
SUBJECTIVE

CC:
HPI: (As listed from Case Study Information)
Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent). Get it solved now!

OBJECTIVE
General:

VS BP, HR, RR, Weight, Height, BMI
Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
POC Testing (any Point of Care (POC) testing specifically performed in the office):
What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.

PLAN

Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.

Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.

Reference no: EM133819569

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