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Medical Terminologies

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Pregunta:

What is a chart note

Autor: James Marion Endrina Entice



Respuesta:

Also called progress note or follow-up note is dictated by a physician after talking with, meeting with, or examining a patient, usually in an outpatient setting, although progress notes are occasionally dictated on hospital inpatients. Contains a concise description of the patient's presenting problem, physical findings, and the physician's plan of treatment, and may also include the results of laboratory tests. can vary in length from one sentence to one or more pages, with the average note being two to four paragraphs long. Are sometimes dictated in an informal, staccato style using clipped sentences, abbreviations, and brief forms. There are numerous formats for this.


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