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  • Commuication For Nurses

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    Genesis Fernandez
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    Patient notes should include the patient's name, date of visit, chief complaint, history of present illness, past medical history, medications, physical exam findings, assessment, and plan of care. The notes should be organized, accurate, and avoid abbreviations or shorthand terms that could cause confusion or be misinterpreted. All entries must be dated and signed by the provider to ensure accountability and authenticity of the medical record.

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    Patient notes should include the patient's name, date of visit, chief complaint, history of present illness, past medical history, medications, physical exam findings, assessment, and plan of care. The notes should be organized, accurate, and avoid abbreviations or shorthand terms that could cause confusion or be misinterpreted. All entries must be dated and signed by the provider to ensure accountability and authenticity of the medical record.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    5 views8 pages

    Commuication For Nurses

    Uploaded by

    Genesis Fernandez
    Patient notes should include the patient's name, date of visit, chief complaint, history of present illness, past medical history, medications, physical exam findings, assessment, and plan of care. The notes should be organized, accurate, and avoid abbreviations or shorthand terms that could cause confusion or be misinterpreted. All entries must be dated and signed by the provider to ensure accountability and authenticity of the medical record.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    of 8

    Writing basic patient notes

    .

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