Bullets for an Exam?
Is this the whole note?
Is this a new or established patient, consult or other?
Shown as is:
HPI: Patient is a 33 y/o male, s/p assault with positive loss of consciousness who was brought to the ER with a right sided scalp laceration which was staples in ER. Ct of head shows linear nondisplaced parietal skull fx with small amount of intracranial air. No reported seizure ativity or mental status changes.
CC: I would use s/p assault w/ + loss of consciousness
HPI: Location - right sided scalp lac
ROS: (2) you could use no seizures (neuro) no mental status changes (psych)
Problem Focused History
New problem, no work up (that I can tell)
Acute Complicated Injury - Moderate Risk
What do you think?
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