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The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
In ophthalmology, gonioscopy is a routine procedure that measures the angle between the iris and the cornea (the iridocorneal angle), using a goniolens (also known as a gonioscope) together with a slit lamp or operating microscope. [1] [2] Its use is important in diagnosing and monitoring various eye conditions associated with glaucoma.
A pelvic examination is the physical examination of the external and internal female pelvic organs. [1] It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma (e.g. sexual assault).
Supporting documents can be added to the original document as an attachment for clarification or recording data. Attachments should be referenced at least once within the original document. Ideally, each page of the attachment is clearly identified (i.e. labeled as "Attachment X", "Page X of X", signed and dated by person who attached it, etc.)
Crew members on board the passenger jet that collided with a Black Hawk helicopter and crashed two weeks ago near Washington, D.C., have been awarded posthumous honors by the regional airline that ...
It should not however, be used as a replacement for the gonioscopy examination but rather be used as a means of refuting or confirming the results of a gonioscopy examination. [3] The Van Herick's technique has become the most commonly used qualitative method of assessing the size of the anterior chamber angle (ACA).
The procedure begins by gently scraping or sampling the cells of the cervix using a special spatula, brush or swab. Some women experience temporary bleeding from this procedure. The scrapings are placed on a slide, covered with a fixative for later examination under a microscope to determine if they are normal or abnormal. [19]
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.