영어 해석좀 부탁드려여... 책한장반불량이거든여..(내공드려여)
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게시물 수정 , 삭제는 로그인 필요
핵석좀 부탁드려여..
의학용어가 있어서 어렵겠지만 할수있는데까지 부탁드립니다.
대문자는 그냥 쓰시면 되구요..
수요일까지 부탁드려여 (저녁 10시)
Writing Interim (Progress) Notes
In an interim (Progress) note, not every category normally addressed in an initial note will be included. Use only the information obtained while reassessing the patient during treatment sessions.
If a patient's status is unchanged and the area addressed is extremely important, it is acceptable to address the area and state that it is unchanged. However, for the sake of the reader, the unchanged status should be briefly described.
EXAMPLE
(CORRECT)
Transfers :Supine ↔ sit unchanged ; still repuires mod +1 assist.
When stating that the patient's status is unchanged, it is important to make sure that all of the evaluation skills and methods available have been used. In the example above, perhaps the amount of assistance needed by the patient is unchanged, but the patient is performing the transfer more quickly (5 minutes to perform the transfer versus 10 minutes).
EXAMPLE
(CORRECT)
Transfers : Supine ↔ sit unchanged ; still requires mod + assist. but performance of transfer requites 5 min. on this date (vs. 10min. initially required). Transfer is becoming more functional.
Date used for comparison purposes can also be included. In the example above, without the comparative data, the fact that the performance of the transfer required 5 minutes would seem insignificant to the reader. The reader may not take the time to look at a previous written note in order to obtain the patient's former status, or the reader may not have the previous note available.
Information addressed in interim notes should include areas addressed in the last set of short term goals written. For example, if a goal is set for the patient to be able to roll supine →sidelying ⓡ(대문자) independently within 1 week, the patient's rolling status should be addressed under O in the next interim note.
As mentioned previously, when writing notes, it is important ot know the requirements of both the facility and the third-party payers. In some areas of the country, certain third-party payers require listing both the treatment the patient received and the patient's reaction to the treatment.
This can be listed in the O part of the note under reaction to treatment.
EXAMPLE
(CORRECT)
Reaction to Rx : Pt. received 30 min. of gait training on this date emphasizing correction of gait deviation & correction of balance deficits. Responded well to verbal cues but could not cont. to correct gait deviations s (위에줄) verbal cues
Writing Discharge Notes
The completeness of the O section of a discharge note varies greatly among practice settings. In some facilities, the discharge note is similar to an interim note and is an update of the patient's status since the last interim note was written. In other facilities, the discharge note is a more complete summary of the patient's condition upon discharge from the facility and, in format and length, is more similar to the initial note. Still other facilities use a format that summarizes the patient's condition upon beginning therapy, the general course of therapy, and the patient's status upon discharge from therapy.
Types of notes can also vary depending upon who will be reading the note. For example, a note that is forwarded to a nursing home or home health agency might be a complete summary of the patient's condition, whereas a note that will go the medical records storage when the patient is discontinued may simply update the patient's status since the last interim note was written. The home health or nursing home therapist may receive only the discharge summary from an acute or rehabilitation facility, so a more complete note is needed. For the purposes of this workbook, the discharge note is to be considered a complete summary of the patient's status upon discharge and course of therapy, and you are to address all areas of objectives data measured and / or remeasured during treatment.
Summary
The O section of the note is a very important section. It should be included in every type of note, whether it is an intial, interim, or discharge note and whether a traditional SOAP format or a SOAP format using functional outcomes as its emphases is used. The information should be organized under headings, should be written in a clear and concise manner, and should list the results of objective measurement procedures performed by the therapist.
The following worksheets give practice at the skills needed to write the O part of a note. Four worksheets are included because this portion of the note includes so many different types of information. After reviewing this chapter, working with the following worksheets. and using the answer sheets to correct the worksheets, you should be able to write the objective portion of a note easily
의학용어가 있어서 어렵겠지만 할수있는데까지 부탁드립니다.
대문자는 그냥 쓰시면 되구요..
수요일까지 부탁드려여 (저녁 10시)
Writing Interim (Progress) Notes
In an interim (Progress) note, not every category normally addressed in an initial note will be included. Use only the information obtained while reassessing the patient during treatment sessions.
If a patient's status is unchanged and the area addressed is extremely important, it is acceptable to address the area and state that it is unchanged. However, for the sake of the reader, the unchanged status should be briefly described.
EXAMPLE
(CORRECT)
Transfers :Supine ↔ sit unchanged ; still repuires mod +1 assist.
When stating that the patient's status is unchanged, it is important to make sure that all of the evaluation skills and methods available have been used. In the example above, perhaps the amount of assistance needed by the patient is unchanged, but the patient is performing the transfer more quickly (5 minutes to perform the transfer versus 10 minutes).
EXAMPLE
(CORRECT)
Transfers : Supine ↔ sit unchanged ; still requires mod + assist. but performance of transfer requites 5 min. on this date (vs. 10min. initially required). Transfer is becoming more functional.
Date used for comparison purposes can also be included. In the example above, without the comparative data, the fact that the performance of the transfer required 5 minutes would seem insignificant to the reader. The reader may not take the time to look at a previous written note in order to obtain the patient's former status, or the reader may not have the previous note available.
Information addressed in interim notes should include areas addressed in the last set of short term goals written. For example, if a goal is set for the patient to be able to roll supine →sidelying ⓡ(대문자) independently within 1 week, the patient's rolling status should be addressed under O in the next interim note.
As mentioned previously, when writing notes, it is important ot know the requirements of both the facility and the third-party payers. In some areas of the country, certain third-party payers require listing both the treatment the patient received and the patient's reaction to the treatment.
This can be listed in the O part of the note under reaction to treatment.
EXAMPLE
(CORRECT)
Reaction to Rx : Pt. received 30 min. of gait training on this date emphasizing correction of gait deviation & correction of balance deficits. Responded well to verbal cues but could not cont. to correct gait deviations s (위에줄) verbal cues
Writing Discharge Notes
The completeness of the O section of a discharge note varies greatly among practice settings. In some facilities, the discharge note is similar to an interim note and is an update of the patient's status since the last interim note was written. In other facilities, the discharge note is a more complete summary of the patient's condition upon discharge from the facility and, in format and length, is more similar to the initial note. Still other facilities use a format that summarizes the patient's condition upon beginning therapy, the general course of therapy, and the patient's status upon discharge from therapy.
Types of notes can also vary depending upon who will be reading the note. For example, a note that is forwarded to a nursing home or home health agency might be a complete summary of the patient's condition, whereas a note that will go the medical records storage when the patient is discontinued may simply update the patient's status since the last interim note was written. The home health or nursing home therapist may receive only the discharge summary from an acute or rehabilitation facility, so a more complete note is needed. For the purposes of this workbook, the discharge note is to be considered a complete summary of the patient's status upon discharge and course of therapy, and you are to address all areas of objectives data measured and / or remeasured during treatment.
Summary
The O section of the note is a very important section. It should be included in every type of note, whether it is an intial, interim, or discharge note and whether a traditional SOAP format or a SOAP format using functional outcomes as its emphases is used. The information should be organized under headings, should be written in a clear and concise manner, and should list the results of objective measurement procedures performed by the therapist.
The following worksheets give practice at the skills needed to write the O part of a note. Four worksheets are included because this portion of the note includes so many different types of information. After reviewing this chapter, working with the following worksheets. and using the answer sheets to correct the worksheets, you should be able to write the objective portion of a note easily