Ø ABDOMEN
Ø ACTIVITIES
Ø ADDENDUM
Ø ADMITTING DIAGNOSES
Ø ALLERGIES
Ø ANESTHESIA
Ø ANESTHESIOLOGIST
Ø ANTIBIOTICS
Ø ASSESSMENT
Ø IMPRESSION
Ø ASSESSMENT AND PLAN
Ø ASSISTANT
Ø AXIS I
Ø AXIS II
Ø AXIS III
Ø AXIS IV
Ø AXIS 5
Ø BACK
Ø CARDIOVASCULAR
Ø CDU DISCHARGE NOTE
Ø CDU PROGRESS NOTE
Ø CDU TRANSFER NOTE
Ø CENTRAL NERVOUS SYSTEM
Ø CHEST
Ø CHIEF COMPLAINT
Ø COMPLICATIONS
Ø CONCLUSIONS
Ø CONDITION ON DISCHARGE
Ø CONSENT
Ø CONSULTATIONS
Ø CONSULTING PHYSICIAN
Ø COUNTS
Ø CURRENT MEDICATIONS
Ø DESCRIPTION OF PROCEDURE
Ø DIAGNOSES
Ø DIET
Ø DIET AND EXERCISE
Ø DIFFERENTIAL DIAGNOSES
Ø DISCHARGE ACTIVITIES
Ø DISCHARGE MEDICATIONS
Ø DISPOSITION
Ø DRAINS
Ø EMERGENCY DEPARTMENT COURSE
Ø ESTIMATED BLOOD LOSS
Ø EXTREMITIES
Ø FAMILY HISTORY
Ø FAMILY PHYSICIAN
Ø FINAL DIAGNOSES
Ø FINDINGS
Ø FOLLOWUP
Ø GASTROINTESTINAL
Ø GENERAL
Ø GENITOURINARY
Ø GYNECOLOGIC HISTORY
Ø HEART
Ø HEENT
Ø HISTORY
Ø HISTORY OF PRESENT ILLNESS
Ø HOSPITAL COURSE
Ø IMMUNIZATIONS
Ø INDICATIONS
Ø INSTRUMENT USED
Ø INTRAVENOUS FLUIDS
Ø LABORATORY DATA
Ø LOCATION
Ø LUNGS
Ø MEDICATIONS
Ø MEDICATIONS ON ADMISSION
Ø MEDICAL DECISION MAKING
Ø MODE OF ARRIVAL
Ø MUSCULOSKELETAL
Ø NAME OF PROCEDURE
Ø NECK
Ø NEUROLOGIC
Ø PAST MEDICAL HISTORY
Ø PAST SURGICAL HISTORY
Ø PATHOLOGY
Ø PELVIC
Ø PHYSICAL EXAMINATION
Ø PHYSICAL EXAMINATION ON ADMISSION
Ø PLAN
Ø POSITION
Ø POSTOPERATIVE CONDITION
Ø POSTOPERATIVE DIAGNOSES
Ø PREMEDICATION
Ø PREOPERATIVE DIAGNOSES
Ø PRIMARY CARE PHYSICIAN
Ø PROGNOSIS
Ø PROVISIONAL DIAGNOSES
Ø PULMONARY
Ø RADIOLOGICAL STUDIES
Ø REASON FOR ADMISSION
Ø REASON FOR CONSULTATION
Ø REASON FOR HOSPITALIZATION
Ø RECOMMENDATIONS
Ø RECTAL
Ø REFERRING PHYSICIAN
Ø RESPIRATORY
Ø REVIEW OF SYSTEMS
Ø SECONDARY DIAGNOSES
Ø SKIN
Ø SOCIAL HISTORY
Ø SPECIMENS
Ø SUMMARY
Ø SURGEON
Ø TIME SEEN
Ø TOURNIQUET TIME
Ø VITAL SIGNS
