VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWCN3.m

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2009-11-29 13:37:14 -05:00
DVBCWCN3 ;ALB/RLC CRANIAL NERVES WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. Onset, course since onset.
;; 2. Symptoms.
;; 3. Current treatment, response, side effects.
;; 4. Effects of condition on occupational functioning and daily activities.
;; 5. History of hospitalizations or surgery, location and dates, if known,
;; reason or type of surgery.
;; 6. History of trauma to a cranial nerve, date, type, nerve.
;; 7. History of neoplasm:
;;
;; a. Date of diagnosis, diagnosis.
;; b. Benign or malignant.
;; c. Types of treatment, dates.
;; d. Last date of treatment.
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;;
;; 1. Describe in detail specific motor and sensory impairment, quantifying
;; as much as possible.
;; 2. If smell or taste is affected, please also complete the appropriate
;; worksheet.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;E. Diagnosis:
;;
;; 1. Identify the nerve and the side.
;; 2. Identify the disorder (i.e., paralysis, neuritis, neuralgia).
;; 3. State etiology.
;;
;;
;;Signature: Date:
;;END