Category Archives: Medical Recording

Sample of a Medical Recording on a Patient with Watery Nipple Discharge

Sample of a medical recording on a patient with watery nipple discharge with explanation, advice and informed consent. Note: the reliance on physical examination for a diagnosis. ROJ@17feb2

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Sample of Medical Recording on a Thyroid Patient

Sample of a medical recording on a thyroid patient with explanation and advice and informed consent. Note the use of benefit, risk, cost, availability comparison of diagnostic options. ROJ@17feb2

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Medical Recording in the Clinic

In the medical clinic, when a physician sees patients, he / she has to do medical recording or medical records. Medical recording will be operationally defined as making records of findings, treatment, plans, and advices of a physician after he … Continue reading

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Spelling out to label LEFT in Medical Records

In a medical recording with drawing or diagram, when putting a label as to side, right or left, instead of writing (R) and (L), I spell out “Right” and “Left”, particularly “Left.”  An “L” can easily be tampered into an … Continue reading

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Using a Null Sign to Mean Negative in Medical Records

When I draw or make diagram for the results of my physical examination findings in a medical record, I use the null sign to mean negative. Before I use these two symbols: (+) to mean positive and (-) to mean … Continue reading

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