Question

Which of the following would be documented in ED Course?

1) Review of systems
2) Orders
3) Family history
4) Interpretations
5) Re-evals
6) Disposition note
7) Treatments
8) Physical exam
9) History of present illness

Answer 1

In an ED course, various items would be documented, such as review of systems, orders, family history, interpretations, re-evals, disposition note, treatments, physical exam, and history of present illness.

Step-by-step explanation:

In an ED course, several items would be documented, including:

1. Review of systems - This refers to a systematic assessment of the patient's body systems, documenting any symptoms or abnormalities.
2. Orders - These are the specific instructions given by the healthcare provider for diagnostic tests, medications, treatments, or consultations.
3. Family history - This includes information about the patient's family members and any relevant medical conditions that might be hereditary.
4. Interpretations - This refers to the analysis and explanation of diagnostic test results or imaging studies.
5. Re-evals - These are subsequent evaluations or assessments of the patient's condition.
6. Disposition note - This documents the final decision regarding the patient's treatment and whether they are discharged or admitted.
7. Treatments - These are the specific interventions or therapies provided to the patient.
8. Physical exam - This includes the assessment of the patient's vital signs, general appearance, and examination of specific body systems.
9. History of present illness - This refers to the patient's account of the current symptoms, including their onset, duration, and associated factors.