Kõik kogukonna mallid
Malli struktuur
See on struktuur, mida Notat järgib visiidi põhjal märkme kirjutamisel — sa ei täida seda kunagi käsitsi.
Coroner Note Date and Time of Examination: [Date and time] Decedent Identification: [Name, age, gender] [Case number] [Location of examination] Circumstances of Death: [Brief summary of events leading to death] [Location where decedent was found] [Who discovered the decedent] [Relevant history or background information] External Examination: (hyphenated list) - [General appearance] - [Clothing and personal effects] - [Identifying marks, scars, tattoos] - [Evidence of trauma or injury] - [Postmortem changes (rigor mortis, livor mortis, decomposition)] - [Other notable findings] Internal Examination: (hyphenated list) - [Head and brain findings] - [Neck findings] - [Chest and heart findings] - [Abdominal organ findings] - [Musculoskeletal findings] - [Other relevant internal findings] Ancillary Studies: (hyphenated list) - [Toxicology samples collected] - [Radiology studies performed] - [Other laboratory tests] Cause of Death: [Summary statement of cause of death] [Manner of death: Natural, Accident, Suicide, Homicide, Undetermined] Comments: [Additional relevant observations or recommendations] [Pending studies or follow-up required]
Jagas
JW
Dr. James Whitfield
Internal Medicine Specialist, United Kingdom
Kuidas see Notatis töötab
Lisa see mall oma malliteeki, salvesta visiit nagu tavaliselt ja Notat koostab märkme täpselt selles struktuuris, kasutades visiidist eraldatud kliinilisi fakte. Sina vaatad üle, muudad ja allkirjastad.
Proovi Notatit — see on tasuta