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> Chart Review
Chart Review
Patient Information
Verify patient's name, date of birth, and medical record number
Confirm date of service and provider information
Medical History
Review past medical history for relevant information
Note any previous surgeries or procedures
Medications
Document current medications and dosages
Check for any allergies or adverse reactions to medications
Vital Signs
Review vital signs including blood pressure, heart rate, temperature, and oxygen saturation
Note any abnormalities or trends in vital signs
Compare current vital signs to previous measurements
Document method of obtaining vital signs (e.g. manual vs automated blood pressure)
Assess for any signs of distress or discomfort during vital sign measurements
Consider potential causes for abnormalities in vital signs (e.g. pain, anxiety, medication side effects)
Review any interventions or treatments initiated based on abnormal vital signs
Laboratory Results
Analyze recent laboratory results including blood tests, urine tests, and imaging studies
Identify any abnormal findings or values outside of normal range
Assessment and Plan
Review provider's assessment and plan for the patient
Ensure that appropriate follow-up appointments or tests are scheduled
Additional Notes
Document any additional observations or concerns
Communicate findings with the healthcare team as needed
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