Sample #2. Examples of possible reports (continued) Number of tumors by process completed, by date received Interval between diagnosis data and date abstracted, and between diagnosis date and date tumor record entered in CCR system, by facility Status of follow-up by facility and diagnosis year for CCRs collecting patient follow-up There is no evidence of any focal area of consolidation. PROCEDURE IN DETAIL: The patient was identified prior to operative area and holding area the correct eye was identified with a YES. A faint rounded density is seen in the base of the left lower hemithorax probably representing a nipple shadow. CHEST X-RAY TWO VIEWS. For example, for a normal abdominal exam, you could report that “the patient’s abdomen is soft, non-tender, and non-distended, with normoactive bowel sounds.” Results of Laboratory Testing, Imaging, and Other Diagnostics REASON FOR CONSULTATION: Psychiatric evaluation for followup. INSTRUCTIONS. COMPARED. Contact Clinical Consultants, Tom Rybarczyk at 313-378-8359 or Corinne Vignali at 313-969-0417 with any questions. diagnosis that matches the signs and symptoms with which the patient has presented. A quick note: resist the urge to report an exam as being “normal.” Instead, report your findings. REASON FOR EXAMINATION: Fever, aches and pains/flu-like symptoms. The progress report specifies the patient's mood, communication, appearance, emotional status, mental stability, interventions, and respond to treatment, and the report summary. EHR Patient Report Instructions: Epic Reports in Epic EHR can be used to identify appropriate patients within the practice panel not at treatment goal. DISCUSSION: The lungs are well aerated. His expectations for treatment are that Jill will not try to kill herself, will become more For example, a patient presenting with chest pain who is diagnosed with a ST segment elevation myocardial infarction will have “STEMI” listed as the healthcare need of highest priority on the list. The patient will benefit from ongoing supportive psychotherapy and vocational counseling, and at this time, should remain on his current regimen, which includes monitoring of his CBC while on Clozaril. Alternatively, a patient presenting to a community phar- These reports enable the practice to analyze clinical data about their patients based on specific information, such as: Diagnosis… DATE OF CONSULTATION: MM/DD/YYYY. INDICATIONS FOR PROCEDURE: The patient has noticed visual loss and impairment of visual acuity in the left eye over the last phase after diagnosis and discussion of surgery, risk and benefits, the patient opted for cataract surgery in the left eye. Sample Patient Report 1875 N. Lakes Place • Meridian, Idaho • 83646 • USA • 208-846-8448 • www.acugraph.com REFERRING PHYSICIAN: John Doe, MD. This Sample Patient Progress Report Template has the patient's personal information, physiological and psychological health progress. Client/Family/Referral Source statement of need and treatment expectations: Mr. Sprat is concerned about Jill’s recent suicidal ideation. Nursing diagnoses vs medical diagnoses vs collaborative problems. Name (Product): To receive your incentive payment, you must submit the patient's medical record to support the information you have entered on this request. Report Date: 10-03-06 Sample Diagnostic Assessment Referral Source: Jill was referred by her father, Jack Sprat. 313-378-8359 or Corinne Vignali at 313-969-0417 with any questions information you have entered on this request is. Suicidal ideation is concerned about Jill ’ s recent suicidal ideation contact Clinical Consultants, Tom Rybarczyk at or... 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