obgyn patient care report

What is a patient care report?

A patient care report is a document written by medical professionals to report about the patient’s wellbeing, care and status. This document consists of the result of the assessment and the evaluation of the patient being done by the EMTs or the EMS.

Who can write reports in healthcare?

A lot of people believe that only nurses or health care workers can write reports. Most specifically patient care reports or anything that may be related to an incident report that often happens in hospitals or in some health care facilities.

How do I log in to the patient portal?

The Patient Portal provides access to features that will save you time and effort. If you are experiencing issues with logging in to your patient portal, please click “Using Mobile Phone” on the “Access Patient Portal” page to log in with your name and DOB. Please call your provider’s office directly for immediate needs or questions.

What should a gynecological history include?

Menstrual historyLast menstrual period (LMP) - date of first day of bleeding.Cycle length and frequency - eg, 5/28, five days of bleeding every 28 days.Heaviness of bleeding. ... Presence or absence of intermenstrual bleeding (IMB).Presence or absence of postcoital bleeding (PCB).Age of menarche/menopause.More items...•

What are the responsibilities of an OB-GYN?

OB/GYNs care for women during pregnancy, giving advice and performing tests such as ultrasounds and fetal heart rate monitoring to check on the health of the developing fetus and the mother. Obstetricians perform the delivery, and if necessary perform a surgical caesarean section.

How do I report OB?

Report bad hospital care and safety issues to regulators: If you or a loved one has experienced or witnessed bad hospital care, you can file a report with your state's hospital regulatory agency, which is often a part of your state's health department.

What health problems do Obgyn have?

What conditions do OB-GYNs treat?abnormal bleeding.pelvic pain.genital itching.urinary incontinence.urinary tract or vaginal infections.endometriosis.breast disorders.hormonal disorders.More items...

What is the difference between a gynecologist and an OB-GYN?

Obstetrics involves care during pregnancy, childbirth, and the postpartum period. Gynecology deals with reproductive health and the functions and diseases specific to women and girls.

Is being an OB-GYN stressful?

A 2017 report by the American College of Obstetricians and Gynecologists (ACOG) states, "The pace of life and its stresses, impact from multitasking, overwhelming information exposure, and electronic medical record expectations have led to some degree of physical or emotional exhaustion or lack of motivation.

What is a medical report?

A medical report is a comprehensive report that covers a person's clinical history. A medical report is a vital piece of evidence that can validate and support your claim for Social Security Disability benefits.

What is obstetrical patient?

Obstetrics. An obstetrician specializes in obstetrics, which deals with all aspects of pregnancy, from prenatal care to post-natal care. An obstetrician delivers babies, whereas a gynecologist does not.

What is the most common gynecological problem?

Polycystic Ovarian Syndrome (PCOS) PCOS is the most common problem amongst young girls in this era.

What is the most common gynecological condition?

Common gynecological problems include: Cervical Dysplasia. Menstrual Disorders. Pelvic Floor Prolapse. Pelvic Pain.

What is the most common gynecological disease?

5 Most Common Gynaecological ProblemsDysmenorrhea. Suffering from lower back pain or abdominal pain during periods is very common. ... Ovarian Cysts. Ovarian cysts come in various sizes. ... Endometriosis. ... PCOD or Polycystic Ovarian Disease. ... Urinary Tract Infection (UTI)

What is a gynecologic history?

GYNECOLOGIC HISTORY: An abnormal Pap smear that resolved, then demonstrated by colposcopy.

What was the surgical course for a 25 cm left ovarian mass?

HOSPITAL COURSE: The patient was admitted for exploratory laparotomy and definitive surgery. Approximately 25 cm left ovarian mass was identified and removed and sent for frozen section. The surgery was performed via midline incision. An abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, and right hypogastric lymph node dissection were performed while awaiting frozen section from pathology. The surgery was done without complications, and the final pathology report was benign mucinous cystadenoma. No additional procedures were required. The patient’s postoperative course was uncomplicated aside from her anxiety and psychiatric history. The patient was then discharged to home on postoperative day 4 in stable and satisfactory condition.

How many years prior to hysteroscopy for infertility?

PREVIOUS SURGICAL HISTORY: Hysteroscopy one year prior for infertility workup.

What position was the patient placed in the operating room?

DESCRIPTION OF OPERATION: The patient was brought into the operating room where she was laid in the supine position. After adequate general anesthesia and endotracheal intubation had been obtained, the patient was placed in the lithotomy position. Foley catheter was placed. The patient was placed back in the supine position. The abdomen was then prepped and draped using the usual sterile technique.

What was the uterus exteriorized?

The uterus was then exteriorized and cleared of all clots and debris. The uterine incision was repaired with #1 chromic in a running-locking fashion. The uterus was then returned to the abdominal cavity, and the abdominal cavity was cleared of all clots and debris.

What was removed from the patient's abdominopelvic cavity?

At this time, instruments were removed from the patient’s abdominopelvic cavity. Vaginal cuff closure and peritoneum were incorporated into one layer with 0 Vicryl suture in a continuous running interlocking fashion. Hemostasis was noted to be achieved. Foley catheter was then placed yielding clear amber urine. A vaginal packing with Premarin cream was placed to provide support during the healing process. The patient tolerated the procedure well and was taken to the recovery room in a stable condition. Sponge and needle counts were correct x3.

What Is a Patient Care Report?

We often hear of care reports based on by medical teams or by medical authorities. Yet, we are not sure how this differs from the kind of report that is given to us by the same people. So this is the time to make it as clear as possible.

How to Write a Patient Care Report?

Where do you even begin when you write a patient care report? A lot of EMS or EMTs do know how to write one since they are trained to do so.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the information necessary for the assessment and evaluation of a patient’s care.

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very careful and very meticulous when writing these kinds of reports. Every detail counts.

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make sure that you have all the information correctly. One wrong information can cause a lot of issues and problems.