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Physical Examination Name Sports Date Sex Age Birthdate SS# Height (in.) Weight Pulse B.P. (Seated Brachial) Vision: R 20/ L 20/ Corrected: YES NO Pupil Size Light Reflex GENERAL Normal Abnormal Findings

How to fill out general normal abnormal findings

To fill out general normal abnormal findings, follow these steps:

1. Begin by observing and documenting the overall appearance and behavior of the subject or patient. Note any noticeable physical characteristics, mood, or demeanor that may be relevant to the findings.
2. Conduct a comprehensive examination of the specific area or system being assessed. This may involve using equipment or performing specific tests to gather objective data. Record all relevant findings accurately and thoroughly.
3. Classify the findings into three categories: normal, abnormal, or unclear. Normal findings refer to results that fall within the expected range for a particular individual or population. Abnormal findings indicate deviations or abnormalities that may require further investigation or medical attention. Unclear findings are those that are inconclusive or require more information to determine their significance.
4. Describe each finding in detail, using appropriate terminology and providing relevant contextual information. This includes noting the location, size, shape, color, consistency, and any other relevant characteristics. Be thorough but concise in reporting the findings.
5. If applicable, compare the current findings to previous or baseline data to identify any changes or trends. This can provide valuable insights into the individual's health status or progress over time.

Who needs general normal abnormal findings?

General normal abnormal findings are essential for various healthcare professionals, including physicians, nurses, and medical researchers. These findings can aid in diagnosing medical conditions, monitoring treatment effectiveness, and assessing overall health and well-being. Additionally, these findings can be used for documentation, medical record-keeping, and communication among healthcare providers.

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What is general normal abnormal findings?

General normal abnormal findings refer to the results or observations that are classified as typical, expected, or unusual during a medical examination or diagnostic test.

Who is required to file general normal abnormal findings?

Healthcare professionals such as doctors, nurses, and medical technicians are required to document and file general normal abnormal findings.

How to fill out general normal abnormal findings?

General normal abnormal findings should be recorded accurately and thoroughly in the patient's medical record using standardized terminology and coding systems.

What is the purpose of general normal abnormal findings?

The purpose of documenting general normal abnormal findings is to track and monitor changes in a patient's health status, aid in diagnosis, and guide treatment planning.

What information must be reported on general normal abnormal findings?

Information such as vital signs, physical exam findings, laboratory results, imaging findings, and other clinical data relevant to the patient's condition must be reported on general normal abnormal findings.