The opinions of physicians
Screening
After speaking with a patient on the phone, the correspondence should be documented in the patient's chart.
All correspondence should be documented in the patient's chart after speaking with them.
Auscultation
by crossing your arms
Patient status
a medical assistant should never code a patient as having what unless its is documented in medical record
The type and duration of therapy sessions, the presenting problems or symptoms of the patient, the therapeutic interventions used, and the progress made by the patient are frequently documented in the patient record and are major billing factors for the Psychiatric therapy subsection.
In the prehospital setting, the most beneficial assessment for differentiating hemorrhagic shock from neurogenic shock is the evaluation of vital signs, particularly blood pressure and heart rate. Hemorrhagic shock typically presents with hypotension and tachycardia due to blood volume loss, while neurogenic shock often shows hypotension with bradycardia due to loss of sympathetic tone. Additionally, assessing the patient's level of consciousness and skin temperature can provide further clues, as neurogenic shock may present with warm, dry skin and altered mental status.
the patient has severe asthma and requires frequent therapy with oral steroids
patient record