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Physical Medicine and Rehabilitation Medical Transcription Chart Note Example

SUBJECTIVE: The patient is without complaints today. However, he would nod off at times during the bedside evaluation. His father was at the bedside as well.

OBJECTIVE: Temperature 98.2, pulse 86, respirations 18, and blood pressure 92/52. Intermittent catheterization volume recorded so far today was 180 mL. The patient had a bowel movement earlier today. Head and neck examination showed the patient closing his eyes and nearly falling asleep one occasion. However, pupils are equal, round, and reactive to light. A Miami J collar was in place. Heart and lung examinations were within normal limits, except for a paradoxical pattern of respiration. The abdomen was soft and nontender with active bowel sounds. An abdominal binder was worn. The sacral dressing was intact. There was no lower extremity edema.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient is participating fully with encouragement in therapies. Discussions about spinal cord injury have been started. Continue comprehensive inpatient rehabilitation evaluation and treatment. Continue the prednisone taper.
2. Spine stability: Stable with Miami J collar. Continue present management.
3. Orthopedic: Surgical wounds are healing well. Continue spine precautions. The patient is scheduled for orthopedic followup next week.
4. Pain: Under good control. Perhaps, the patient may be able to be weaned from some of the medications as he is easily falling asleep. However, this could also be tiredness because of his decreased endurance.
5. Stage III sacral decubitus ulcer: Stable. The patient’s father again asked whether he could have a KinAir bed. He was told that the AccuMax overlay is appropriate for the patient and that his skin is healing. Continue wound care as written.
6. Pulmonary: Stable. Continue to work on improving the pulmonary status and diaphragm strength.
7. Neuropathic pain in the lower extremities: Reported more so in the left foot. The patient would like to hold off on adding Elavil to his treatment plan at this time. He will continue to use the Neurontin. The patient is aware that the Elavil will not interfere with the healing process.

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