A clinical record whose history cannot be rewritten. Signed notes are immutable and corrections are filed as amendments, medication orders refuse when they cannot be checked against the allergy list, and every read of a member's chart is recorded.
| Drug | Dose | Checked at |
|---|---|---|
| No orders yet. | ||
| Clinician | Purpose | When |
|---|---|---|
| Dr. Adaeze Osei | treatment: chart review | Jul 29 20:22:49 |
| Dr. Adaeze Osei | treatment: chart review | Jul 29 20:22:39 |
| Dr. Adaeze Osei | treatment: chart review | Jul 29 20:15:33 |
| Dr. Adaeze Osei | treatment: chart review | Jul 29 20:10:53 |
| Dr. Adaeze Osei | treatment: chart review | Jul 29 20:10:36 |
| Dr. Adaeze Osei | treatment: chart review | Jul 29 19:57:12 |
| Dr. Adaeze Osei | treatment: chart review | Jul 29 19:56:48 |
| Dr. Adaeze Osei | treatment: chart review | Jul 29 19:54:18 |
Follow up. ECG unremarkable. Reports symptoms improved with rest. Plan: continue monitoring, recheck in six weeks.
Chief complaint: intermittent chest tightness for three weeks. Denies radiation. No shortness of breath at rest. Plan: ECG, basic metabolic panel, follow up in two weeks.
Chief complaint: intermittent chest tightness for three weeks, on exertion only. Denies radiation. No shortness of breath at rest. Plan: ECG, basic metabolic panel, exercise tolerance test, follow up in two weeks.