Medical Documentation Proofreading Example 12

Proofreading


The patient is a 40-year-old female with past medical history from repair of deviated septum by  complication of a Septal perforation. At that time, the patient says that her septal perforation  bother her as she feels that she has very dry air trough her nose as well as occasional epistaxis.  At this time I counselled the patient on the risks and benefits of surgery. She will consider surgery  but at this time, she will like two continue using the saline nasal wash as well as occasional  Bactroban to the nose if there are occasional irritation and crusting which she will apply with the  edge of an Q-tip. We will see her back in three weeks. If the patient does not feel releived from  the Bactroban as well as saline nasalspray wash, we will consider setting the patients for surgery  at this time.


septal perforation



Answer


The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient states that her septal perforation  bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  At this time, I counseled the patient on the risks and benefits of surgery. She will consider surgery, but at this time, she would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the  edge of a Q-tip. We will see her back in three weeks. If the patient does not feel relieved from Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery  at that time.



  • The blue marked one can also be “and,” in which case, “occasional irritation and crusting” is a single idea in the sense that they always came together in the patient’s body.

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