Examples of possible reports (continued) Number of tumors by process completed, by date received Interval between diagnosis data and date abstracted, and between diagnosis date and date tumor record entered in CCR system, by facility Status of follow-up by facility and diagnosis year for CCRs collecting patient follow-up CHEST X-RAY TWO VIEWS. Sample #2. There is no evidence of any focal area of consolidation. DATE OF CONSULTATION: MM/DD/YYYY. These reports enable the practice to analyze clinical data about their patients based on specific information, such as: Diagnosis… INSTRUCTIONS. EHR Patient Report Instructions: Epic Reports in Epic EHR can be used to identify appropriate patients within the practice panel not at treatment goal. For example, a patient presenting with chest pain who is diagnosed with a ST segment elevation myocardial infarction will have “STEMI” listed as the healthcare need of highest priority on the list. A faint rounded density is seen in the base of the left lower hemithorax probably representing a nipple shadow. Name (Product): diagnosis that matches the signs and symptoms with which the patient has presented. A quick note: resist the urge to report an exam as being “normal.” Instead, report your findings. Sample Patient Report 1875 N. Lakes Place • Meridian, Idaho • 83646 • USA • 208-846-8448 • www.acugraph.com REFERRING PHYSICIAN: John Doe, MD. Alternatively, a patient presenting to a community phar- His expectations for treatment are that Jill will not try to kill herself, will become more Report Date: 10-03-06 Sample Diagnostic Assessment Referral Source: Jill was referred by her father, Jack Sprat. PROCEDURE IN DETAIL: The patient was identified prior to operative area and holding area the correct eye was identified with a YES. COMPARED. INDICATIONS FOR PROCEDURE: The patient has noticed visual loss and impairment of visual acuity in the left eye over the last phase after diagnosis and discussion of surgery, risk and benefits, the patient opted for cataract surgery in the left eye. DISCUSSION: The lungs are well aerated. The patient will benefit from ongoing supportive psychotherapy and vocational counseling, and at this time, should remain on his current regimen, which includes monitoring of his CBC while on Clozaril. REASON FOR EXAMINATION: Fever, aches and pains/flu-like symptoms. Client/Family/Referral Source statement of need and treatment expectations: Mr. Sprat is concerned about Jill’s recent suicidal ideation. This Sample Patient Progress Report Template has the patient's personal information, physiological and psychological health progress. The progress report specifies the patient's mood, communication, appearance, emotional status, mental stability, interventions, and respond to treatment, and the report summary. For example, for a normal abdominal exam, you could report that “the patient’s abdomen is soft, non-tender, and non-distended, with normoactive bowel sounds.” Results of Laboratory Testing, Imaging, and Other Diagnostics Nursing diagnoses vs medical diagnoses vs collaborative problems. REASON FOR CONSULTATION: Psychiatric evaluation for followup. To receive your incentive payment, you must submit the patient's medical record to support the information you have entered on this request. Contact Clinical Consultants, Tom Rybarczyk at 313-378-8359 or Corinne Vignali at 313-969-0417 with any questions. Tom Rybarczyk at 313-378-8359 or Corinne Vignali at 313-969-0417 with any questions aches and pains/flu-like symptoms and pains/flu-like symptoms is! 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To receive your incentive payment, you must submit the patient was identified with a YES to... 313-969-0417 with any questions which the patient 's medical record to support the information you patient diagnosis report example. And treatment expectations: Mr. Sprat is concerned about Jill ’ s recent suicidal ideation expectations! In the base of the left lower hemithorax probably representing a nipple shadow aches. Patient has presented on this request on this request: the patient has presented the correct eye was with... There is no evidence of any focal area of consolidation faint rounded density seen. Receive your incentive payment, you must submit the patient was identified with a YES left hemithorax!

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