A sample of what is in a medical folder
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The document contains medical details for a patient named By Simisola the art director who was admitted to Claybrooke Mental Institution. It includes their age, symptoms, mental health diagnosis, current occurrences, and medical treatment plan of 500mg daily of Stelazine. The patient and doctor signatures are at the bottom.
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MEDICAL EVALUATION PERFORMA - UPDATED.docx
This medical evaluation form collects information about a patient's medical history, presenting complaints, past medical history, drug and treatment history, family history, and physical exam findings. The physical exam includes a general exam noting vital signs and appearance, as well as detailed exams of the head, neck, chest, abdomen, extremities, and neurological system. The form is used to document a comprehensive medical evaluation.
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Date ________ Student Name _______________________ Cli.docx
Date:
________
Student Name:
_______________________
Clinical Site:____________________________________
Clinical Site Instructor:___________________________________
__________________________________________
Room #_405_________Client Initials:
____SR___ ____
Client age:
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Gender:
___Male_______
Allergies:
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Code Status: ___Full code______________ ________________
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____N/A___________________________
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__Sodium 135-145_______________
Systems affects:
______________________________________________
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Low level:
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Lab Test #2:
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______________________________________________
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_____________________________________________________________________________
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Student Name:
_______________________________________________
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This document contains a patient's eye exam record including their chief complaint, medical history, medications, allergies and social history. It documents measurements of their vision, dilation of their pupils, examination of their lids, lashes, conjunctiva, cornea, anterior chamber, iris, lens and fundus. Impression and recommendation for follow up with their doctor are also included.
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Allergies:
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Low level:
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San jacinto eye care technology center wrkup sheet 17
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A sample of what is in a medical folder
- 1. Sample of the medical details for the patient By Simisola the art director
- 2. CLAYBROOKE MENTAL INSTITUTION PATIENT PERSONAL FILE Patient name: _________________________ Age: _____ Symptoms: __________________________________________ __________________________________________ __________________________________________ __________________________________________ Mental Health Test Diagnosis: _________________________________________________________ File status: ADMITTED ____________________
- 3. CLAYBROOKE MENTAL INSTITUTION PATIENT REVIEW Current occurrences: __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ Medical treatment plan: 500mg daily of Stelazine ____________________ _____________________ Patient Signature Doctor Signature