Patient Note; Can I write PE that I did not do? - USMLE Forums
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  #1  
Old 03-02-2012
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Help Patient Note; Can I write PE that I did not do?

Do we only write the examination that we performed during the encounter or can we wright everything.
for example if we only auscultate respiratory and CVS. but in the patient note can we also write the HEENT, Abdomen, and soo on......
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Old 03-02-2012
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FA says not to write any examination u have not done on the patient but I am not sure if the person checking the PN will know or not.
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Old 03-02-2012
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well i have question
when i was typing my patient notes took from 15 min because i cant memorize the 1st aif patient form i keep looking to 1st aid
so i took from me 15 min bad i know
i practice only 2 long cases
and another thing in patient notes should we write it like 1st aid ? like PMH : Rheumatoid Arthritis for 2 years on treatment of Methotrexate
or i should type the patient had RA for 2 years on treatment instead of writing PMH :
plz advise me
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Old 03-02-2012
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let us post here all our Questions about PN
so everyone reply here
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Old 03-07-2012
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please dont write what you have not examined...one of my friend failed in his PN and probably because of the same reason.
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