Flow sheet for the medical field?
Medical Field Flow Sheet
Patient Information
* Name:
* Age:
* Sex:
* Medical Record Number:
* Date:
Chief Complaint
* The patient's main reason for seeking medical attention.
History of Present Illness
* A detailed account of the patient's symptoms, including when they started, how they have progressed, and any associated factors.
Past Medical History
* A list of the patient's previous medical conditions, including any surgeries or hospitalizations.
Social History
* Information about the patient's lifestyle, including their occupation, alcohol and tobacco use, and exercise habits.
Family History
* A list of the patient's relatives who have had medical conditions similar to theirs.
Physical Examination
* A detailed examination of the patient's body, including their vital signs, skin, eyes, ears, nose, throat, respiratory system, cardiovascular system, gastrointestinal system, musculoskeletal system, and neurological system.
Laboratory Tests
* A list of the laboratory tests that have been ordered for the patient.
Imaging Studies
* A list of the imaging studies that have been ordered for the patient.
Diagnosis
* The doctor's conclusion about the patient's condition.
Treatment Plan
* A list of the treatments that have been prescribed for the patient.
Prognosis
* The doctor's prediction of the patient's outcome.
Follow-Up Plan
* A list of the follow-up appointments that have been scheduled for the patient.