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Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record.
Letter Aspect Example Questions S Site Where is the pain? Or the maximal site of the pain. O Onset When did the pain start, and was it sudden or gradual? Include also whether it is progressive or regressive. C Character What is the pain like? An ache? Stabbing? R Radiation: Does the pain radiate anywhere? A Associations
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
In Somatic Experiencing therapy, "discharge" is facilitated in response to arousal to enable the client's body to return to a controlled condition. Discharge may be in the form of tears, a warm sensation, unconscious movement, the ability to breathe easily again, or other responses that demonstrate the autonomic nervous system returning to its ...
pain on palpation, Plaster of Paris, Pelvic Organ Prolapse, Progestin Only Pills Post: posterior (see anatomical terms of location) POT: plan of treatment POTS: postural orthostatic tachycardia syndrome: POX: peroxidase: PP: pulse pressure postpartum, that is, postnatal postprandial: PPCS: prolonged post-concussion syndrome: PPD: packs per day
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Theoretically, a certain pattern of signs or symptoms can be directly associated with a certain therapy, even without a definite decision regarding what is the actual disease, but such a compromise carries a substantial risk of missing a diagnosis which actually has a different therapy so it may be limited to cases where no diagnosis can be made.