Medical Documentation Proofreading Example 14

Proofreading

The patients presents today to nursing home with multi medical problems. The nurses report that  she has been confused at times; having incontinent stools, and does poorly. She does has trouble  walking which she attributes to week legs. She feel a couple of months ago. Her appetite has  been good. She has been loosing weight a little bit. She deny diarrhea and vomiting. She does  complain of feeling listless and unambitous and would like to try some Ensure. I ordered yearly  digoxin levels. I increased his Aricept for 10 mg daily. She apparently did have intermittent atrial  fibrillation as reason for being on the digoxin. We will plan to recheck her at a couple of month.  We ordered Health supplement to be taken after each meal, due to her weight loss. She is to  return back to the Clinic in one month to followup.


medical report proofreading for medical scribe students



Answer


The patient presents today to the nursing home with multiple medical problems. The nurses report that  she has been confused at times, having incontinent stools, and does poorly. She does have trouble  walking, which she attributes to weak legs. She fell a couple of months ago. Her appetite has  been good. She has been losing weight a little bit. She denies diarrhea or vomiting. She does  complain of feeling listless and unambitious and would like to try some Ensure. I ordered yearly  digoxin levels. I increased her Aricept to10 mg daily. She apparently does have intermittent atrial  fibrillation as a reason for being on the digoxin. We will plan to recheck her in a couple of months.  We ordered health supplement to be taken after each meal due to her weight loss. She is to  return ____ to the clinic in one month to follow up.

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