Most daily progress notes include a physical exam portion to say how the patient looks, how the heart and lungs sound etc, this was the best exerpt today I found while looking through my patients
"HEEN: WNL, could use a shave"
(HEEN=Head,Ears, Eyes,Nose; WNL=Within Normal Limits)
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1 comment:
A physical examination, medical examination, or clinical examination (more popularly known as a check-up or medical) is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.
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