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report structure - bry20

Posted: Dec 19, 2009

I often get tripped up on this. In a discharge summary, would you do the Physical Exam portion like this, or list it vertically?

Thanks.

PHYSICAL EXAMINATION
Physical exam revealed a sad, frail appearing elderly woman. Pulse: 70 regular. Blood pressure: 130/70. Temperature: 98. Skin: Periumbilical ecchymosis was present along with faint ecchymosis extending into her left lower quadrant. HEENT: Mild conjunctival pallor. Neck: Well-healed thyroidectomy scar. No masses. Lungs: No rales, wheezes or rhonchi. Heart: Grade 2/6 systolic ejection murmur along the lower external border. Abdomen: No liver or spleen enlargement. There was definite fullness in the left lower quadrant with pain on firm palpation. Bowel sounds were present. Extremities were without edema.

Depends on your account specifics. - Cathy

[ In Reply To ..]
I have several accounts and they each want things their own way. Some want the PE in a discharge summary listed with vertical headings just like a PE in an H and P, others want them with capitalized headings in wrap-around format, and others want just a paragraph like you have.

Ditto Cathy - but if I have no acct specifics

[ In Reply To ..]
If I have no guidelines or specifics and have to decide on my own what format to use, for a Discharge Summary PE, I would do one paragraph, using capitalized headings with colons. Pretty much the way you have it.

All kinds of ways to set it up, if no rules, then what you have is fine. - darlene

[ In Reply To ..]
if the person who hired you did not give you any format to go by then, just do it as you have it. All clients/employers have a different take on it.

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