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Old 03-07-2013
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Show Teeth What is the correct order of writing history in patient note

HPI
ROS
ALL
MED
PMH
PSH
OBGYN
FH
SH

Please correct me.
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Old 05-29-2013
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Looks good. I sat the CS exam on March 2013 and I used that format. I passed the exam
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Old 06-05-2013
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Quote:
Originally Posted by ipd2346 View Post
Looks good. I sat the CS exam on March 2013 and I used that format. I passed the exam
CONGRATULATIONS.

BTW can you please let us know the short forms that you used for patient note .......
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Old 06-07-2013
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Thank you
By short forms do you mean mnemonics by any chance?
In which case , I divided my blue sheet into 4 rectangles, and on the RUQ ( right upper quadrant) I wrote : LIQORAAA.
In the RLQ, I wrote PAMHITSFOSSWADES
In the LUQ, left upper quadrant, I wrote the memonic for review of systems: THENFRCSPUB
And in the LLQ, I wrote 2-3 differential diagnoses, based on what I determined from the door information.
All of the above for adults. For Paeds I used for ROS: FEVERCUDS and for the PMH: PAMIFBIGDEALS

I hope this helps. If not please ask me again and I will try to answer.
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Old 06-10-2013
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Quote:
Originally Posted by ipd2346 View Post
Thank you
By short forms do you mean mnemonics by any chance?
In which case , I divided my blue sheet into 4 rectangles, and on the RUQ ( right upper quadrant) I wrote : LIQORAAA.
In the RLQ, I wrote PAMHITSFOSSWADES
In the LUQ, left upper quadrant, I wrote the memonic for review of systems: THENFRCSPUB
And in the LLQ, I wrote 2-3 differential diagnoses, based on what I determined from the door information.
All of the above for adults. For Paeds I used for ROS: FEVERCUDS and for the PMH: PAMIFBIGDEALS

I hope this helps. If not please ask me again and I will try to answer.
Thank you for your guide. But what I really meant is the Short forms that we use during patient note like

HEENT:
NC/AT : normocephalic / atraumatic
LAD: no lymphadenopathy
Cardiac exam (CV):
M/G/R : no murmurs, gallops, rubs
2+ PT/DP B : 2+ posterior-tibial and dorsalis pedis pulses bilaterally
JVD : no jugular venous distension
LE edema: no lower extremity edema
Lung exam:
CTA B : clear to auscultation bilaterally
Abdomen exam:
NT/ND : non-tender, non-distended
HSM : no hepatosplenomegaly
+ BS : bowel sounds present
Back exam:
CVAT : no costovertebral angle tenderness
Neuro:
EOMI / PERRL : extraocular mvmnts intact / pupils equal, round, reactive to light
etc etc.

ALSO PLEASE LET ME KNOW WHAT DO YOU THINK OF ABOVE WRITTEN SHORT FORMS, WILL THEY BE ACCEPTABLE??
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Old 06-10-2013
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hi thanks you!!!
what about neuro. exam. can you share ??
my test is very soon.
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Old 06-10-2013
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Quote:
Originally Posted by romeja View Post
hi thanks you!!!
what about neuro. exam. can you share ??
my test is very soon.
Hi Romeja,
actually I don't know whether the short forms I wrote are acceptable or not so first make sure it is acceptable before writing in PN.(That's what Im trying to do here....)

for Neuro you can add:
CN II-XII intact, no focal deficit

btw, when is your exam? all the best
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