Reexamination sample documentation
Contents
Abdominal exam
Improved
Rexamination Before Discharge Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. Patient feels much better and can tolerate POs. @NAME@ is aware of and understands precautions, as well as need to follow up.
Resolved
Rexamination Before Discharge Before discharge abdominal reexam shows a soft abdomen, nontender, nondistended. @NAME@ feels much better with full resolutions of symptoms and would like to go home. @NAME@ can tolerate POs and, after a long discussion, is aware of and understands precautions as well as need to follow up.
Admit improved
Rexamination Before Admission @NAME@ had significant improvement with symptoms/vitals. Improving with treatment.
ETOH discharge
Rexamination Before Discharge Before discharge @NAME@ was feeling much better with resolution of symptoms, and would like to go home. Tolerating POs. Has a steady gait and non-slurred speech. No tremor. @NAME@ acknowledges that will not drive, operate heavy machinery, etc. while intoxicated. Has a reasonable plan for self care. No SI/HI.
General discharge improved
Rexamination Before Discharge Before discharge @NAME@ was feeling much better with improvent of symptoms, and would like to go home. Tolerating POs.
General resolved
Rexamination Before Discharge Before discharge @NAME@ was feeling much better with full resolutions of symptoms, and would like to go home. Tolerating POs.
Reexam trauma
Rexamination Before Discharge A full tertiary reexam showed @NAME@ to be feeling much better with improvement of symptoms. No additional injuries were noted and patient no change in neurologic and vascular function. Compartments are soft.
Reexam wheeze
Rexamination Before Discharge Before discharge @NAME@ had clear lung sounds bilaterally without evidence of respiratory distress, and feels much better. Would not like any further treatments and would like to go home.
