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Tests specific to HEENT examination Eyes: eye examination and acuity (including ophthalmoscope) Ears: hearing examination and evaluation of tympanic membrane (TM) (otoscope used in evaluation of ears, nose, and mouth) A neurological examination is usually considered separate from the HEENT evaluation, although there can be some overlap in some ...
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
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]
A cheat sheet (also cheatsheet) or crib sheet is a concise set of notes used for quick reference. Cheat sheets were historically used by students without an instructor or teacher's knowledge to cheat on a test or exam. [1] In the context of higher education or vocational training, where rote memorization is not as important, students may be ...
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The assessment and plan (abbreviated A/P" [1] or A&P) is a component of an admission note. Assessment includes a discussion of the differential diagnosis and supporting history and exam findings. The plan is typically broken out by problem or system. Each problem should include: brief summary of the problem, perhaps including what has been done ...
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In 2000, Microsoft released an initial version of an XML-based format for Microsoft Excel, which was incorporated in Office XP. In 2002, a new file format for Microsoft Word followed. [9] The Excel and Word formats—known as the Microsoft Office XML formats—were later incorporated into the 2003 release of Microsoft Office.