Topics Discussed: medical record, device; research and statistics.
Excerpt:"Many hospitals are now using EMR (electronic medical records) or EHR (electronic health records). These are often in a preformatted template to be completed electronically. Because there are many different formats, there is no all-inclusive EMR example. The following section provides an overview of the basic history, progress note, admission orders, and discharge summary. Chapter 5 outlines the newborn physical examination.Identification (ID). State the name, age, sex, and weight of the infant. Include whether the patient or mother was transported from another facility or whether the infant was born at home or within the hospital.
Infant James, a 3-h-old 1800-g white male, is an inborn patient from Baltimore, Maryland.
Chief complaint (CC). The major problems of the patient are usually listed in the order of severity of disease process or occurrence.
- Respiratory distress syndrome.
- Suspected neonatal sepsis.
- Premature birth living child (PBLC).
Referring physician. Include the name, address, and telephone number of the referring physician.
Dr. Macaca Mulatta, Benjamin Franklin Medical..."
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