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ETD Procedural Sedation and Analgesia Note (PSA)
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(A) INTEGRATED SCALE DEVELOPMENT (ISD)
(D) WORD COUNTING
0 - 3 MONTHS
0 0 3
0 3 0 6
0 6 0 18
0 6 0 9
1 0 1 6
1 6 2 0
1 PRE-VERBAL SKILLS
1 SEMANTICS
10 - 12 MONTHS
100 HUE
12-24 MONTHS
13 - 15 MONTHS
16 - 18 MONTHS
19 - 24 MONTH
2 - TONGUE
2 0 3 0
2 RECEPTIVE LANGUAGE SKILLS
2 SYNTAX / MORPHOLOGY
25 - 30 MONTHS
3 - 4 YEARS
3 - JAW AND TEETH
3 0 4 0
3 EXPRESSIVE LANGUAGE SKILLS
3 PRAGMATICS
31 - 36 MONTHS
37 - 42 MONTHS
4 - 6 MONTHS
4 - 6 YEARS
4 0 5 0
4- CHEEK
43 - 48 MONTHS
5 0 6 0
5- HARD PALATE
6 - 8 YEARS
6 LING SOUNDS TEST
6- SOFT PALATE
7 - 9 MONTHS
7 - BREATHING
7 SOUNDS TEST
8 8 11 YEARS
8- DDK ( DIADOCHOKINETIC RATE)
9 POSITION GAZE
< 12 MONTHS
A. ORIENTATION & AWARENESS
A. RISK ASSESSMENT
A.ACTIVITY
ABDOMINAL EXAMINATION
ABDOMINAL HYSTERECTOMY: ANXIETY
ABDOMINAL HYSTERECTOMY: KNOWLEDGE DEFICITS
ABDOMINAL HYSTERECTOMY: NAUSEA & VOMITING (POTENTIAL)
ABDOMINAL HYSTERECTOMY: PAIN
ABDOMINAL HYSTERECTOMY: POTENTIAL OF INFECTION
ABNORMAL MOVEMENTS
ACADEMIC HISTORY
ACCESS METHOD
ACCOMMODATION AND CONVERGENCE
ADDITIONAL TEST
ADMISSION
ADMISSION INFORMATION
ADULT AURAL REHABILITATION-ADULT
ADULT LANGUAGE ASSESSMENT
ADVANCED ELECTROPHYSIOLOGY
ADVERSE OUTCOME DOCUMENTATION
AIRWAY AND CERVICAL PROTECTION
ALLERGIES AND ALERT
ALOPECIA
ALTERATION IN BOWEL ELIMINATION: CONSTIPATION
ALTERATION IN BOWEL ELIMINATION: DIARRHOEA
ALTERATION IN COMFORT: PAIN
ALTERATION IN PATTERNS OF URINARY ELIMINATION: INCONTINENCE
ALTERATION IN PATTERNS OF URINARY ELIMINATION: RETENTION
ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS
ALZHEIMER: ANXIETY
ALZHEIMER: DEFICIENT KNOWLEDGE
ALZHEIMER: INTERFERENCE OF THE THINKING PROCESS DUE TO DISEASE
ALZHEIMER: PATIENT DISABLED TO MEET THEIR CARE AND NEEDS
ALZHEIMER: RISK OF INJURY
AMBULANCE INFORMATION
AMNIOCENTESIS
AMNIOINFUSION
AMNIOREDUCTION
AMPUTATION REVISION PATIENTS: DISRUPTION OF PERSONAL IMAGE
ANAESTHESIA
ANALGESIA
ANATOMIC LOCATION
ANATOMY STRUCTURE & PHYSIOLOGY
ANEMIA: FATIQUE
ANEMIA: HEADACHE
ANEMIA: PALPITATION
ANEMIA: SHORTNESS OF BREATH
ANKYLOSING SPONDYLITIS
ANORECTAL ANOMALY: ABDOMEN DISTENTION
ANORECTAL ANOMALY: VOMITING
ANTENATAL HISTORY
ANTENATAL HYPERTENSION
ANTENATAL PROBLEMS
ANTENATAL SCREENING
ANTERIOR CHAMBER
ANTERIOR CHAMBER
ANTERIOR SEGMENT
ANTERIOR SEGMENT
ANTHROPOMETRIC MEASUREMENTS
ANTHROPOMETRY
ANXIETY: VAGUE UNEASY FEELING OF DISCOMFORT OR DREAD ACCOMPANIED BY AN AUTONOMIC RESPONSE
ARTICULATION
ASCAN
ASPHYXIA: ALTERED RESPONSE OF CENTRAL NERVOUS SYSTEM
ASPHYXIA: ALTERED CARDIAC OUTPUT
ASPHYXIA: ALTERED KIDNEY PERFUSSION
ASPHYXIA: IMPAIRED GAS EXCHANGE
ASSESMENT
ASSESSMENT
ASSESSMENT CHECKLIST (WARD)
ASSESSMENT NEEDED
ASSESSMENT SCORE
ASSESSMENT/INTERVENTION
ASSESSMENTS
ASSIGN CALL CARD
ASSOCIATED PROBLEMS
ATOPIC ECZEMA
ATTENDANCE (FAMILY)
ATTENTION
AUDIOLOGIC REHABILITATION TRAINING
AUDIOMETRY
AUDITORY AWARENESS
AUDITORY COMPREHENSION
AUDITORY MEMORY
AUGMENTATIVE DEVICE EVALUATION
AURAL REHABILITATION STRATEGIES
B. MEMORY
B. PENGULANGAN
B. SOCIAL SUPPORT
B.DAMAGE
BABY
BABY ON PHOTOTHERAPY: KNOWLEDGE DEFICITS
BABY ON PHOTOTHERAPY: POTENTIAL OF DEHYDRATION TO BABY
BABY ON PHOTOTHERAPY: POTENTIAL OF EYE INFECTION
BABY ON PHOTOTHERAPY: POTENTIAL OF SKIN PEELING
BABY ON PHOTOTHERAPY: RISKS OF COMPLICATIONS
BABY ON PHOTOTHERAPY: RISKS OF EYE INJURY
BABY'S RECORD
BACKGROUND INFORMATION
BALANCE & VESTIBULAR
BDAE (ADAPTED)
BEHAVIORAL OBSERVATION AUDIOMETRY (BOA)
BEHAVIOUR & SOCIAL SKILLS AND EDUCATION
BEST CORRECTED VA
BILATERAL TUBAL LIGATION: KNOWLEDGE DEFICITS
BINAURAL MASKING LEVEL DIFFERENCE
BINOCULAR FUNCTION
BIOCHEMISTRY
BIOMETRY
BIRTH AND MEDICAL HISTORY
BIRTH AND NEONATAL HISTORY (WHERE RELEVANT)
BIRTH HISTORY
BODY IMAGE
BREASTFEEDING: ANXIETY
BREASTFEEDING: BREAST ENGORGEMENT
BREASTFEEDING: KNOWLEDGE DEFICITS
BREASTFEEDING: POTENTIAL OF CRACKED / SORE NIPPLE
BREATHING
BRIEF HISTORY
BRONCHO ASTHMA: INSUFFICIENT OF KNOWLEDGE
BRONCHO ASTHMA: RESPIRATORY DISTURATION
BRONCHO ASTHMA: WORRY WHEN SOB ATTACK
BROW
C. AUDITORY PROCESSING & COMPREHENSION
C. CAPACITY TO COOPERATE
C. MENAMAKAN
CAESAREAN
CARDIAC STATUS AT PCI PROCEDURE
CARDIOTHORACIC: IMPAIRED SKIN INTEGRITY
CARDIOTHORACIC: INEFECTIVE BREATHING PATTERN
CARDIOTHORACIC: KNOWLEDGE DEFICIT
CARDIOTHORACIC: PAIN
CARDIOTHORACIC: RISK OF BLEEDING
CARDIOTHORACIC: RISK OF CARDIAC CRRHYTHMIA
CARDIOTHORACIC: RISK OF INFECTION
CARDIOVASCULAR
CARE BABY OF PNEUMOTHORAX: INEFFECTIVE BREATHING PATTERN
CARE BABY ON VENTILATOR: INEFFECTIVE BREATHING PATTERN
CARE OF PREMATURE BABY: ALTERTED NUTRITION
CARE OF PREMATURE BABY: HYPORTHEMIA
CARE OF PREMATURE BABY: INEFFECTIVE BREATHING PATTERN
CARE OF PREMATURE BABY: POOR WEIGHT GAIN
CARE PLAN
CARE PLAN CHEMOTHERAPY
CARE PLAN HAEMOPHILIA
CARE PLAN THALASSEMIA
CARPAL TUNNEL SYNDROME PATIENTS: LIMITED MOBILITY
CASE HISTORY
CATEGORIES OF AUDITORY PERFORMANCES-II (CAP)-II
CATH LAB TO BE COMPLETED BY HUB
CATH LAB VISIT
CENTRAL NERVOUS SYSTEM
CEREBELLAR
CERVICAL CANCER: ANXIETY
CERVICAL CANCER: KNOWLEDGE DEFICITS
CERVICAL CANCER: PAIN
CERVICAL CANCER: POTENTIAL OF FLUIDS AND ELECTROLITE IMBALANCE
CERVICAL CERCLAGE
CERVICAL CERCLAGE
CERVICAL LENGTH
CHAMBERS
CHECKLIST FOR CONTRA INDICATIONS
CHEST PAIN
CHIEF COMPLAINT
CHILD HOSPITALIZED: FEAR
CHILD WITH IDDM: RISK OF COMPLICATION FOR UNSTABLE BLOOD GLUCOSE LEVEL
CHILDHOOD APRAXIA OF SPEECH-PAEDIATRICS
CHORIONIC VILLOUS SAMPLING
CIRCULATION
CLINICAL ASSESSMENT
CLINICAL DIAGNOSIS
CLINICAL DIAGNOSIS AT ADMISSION*
CLINICAL EVALUATION
CLINICAL EXAMINATION AND BASELINE INVESTIGATION
CLINICAL IMPRESSION / DIAGNOSIS
CLINICAL PRESENTATION AND EXAMINATION
CLINICAL SUMMARY
CLINICAL VOICE EVALUATION
COGNITIVE COMMUNICATION NOTE-ADULT
COLLECTION OF FORENSIC SAMPLES
COLLECTION OF MEDICO-LEGAL SAMPLES FOR LABORATORY INVESTIGATION
COLOUR VISON TEST
COLPOSCOPY
COMMENTS
COMPLAINT AND HISTORY
COMPLICATION
COMPLICATIONS OF CONTACT LENS WEAR
COMPONENT
CONCLUSIONS
CONGENITAL DIAPHRAGMATIC HERNIA: INEFFECTIVE BREATHING PATTERN
CONJUNCTIVA
CONJUNCTIVA
CONTACT LENS AFTER-CARE
CONTACT LENS DELIVERY
CONTRACEPTIVE HISTORY
CONVERSATIONAL AND EXPOSITORY SPEECH
CORD PROLAPSE: ANXIETY
CORD PROLAPSE: POTENTIAL OF CORD COMPRESSION
CORNEA
CORNEA
CORNEAL TOPOGRAPHY
CPR TIME LOG
CRANIAL NERVES
CRITERIA
CRITICAL CARE REVIEW AND FAST-TRACK
CURRENT COMPLAINTS
CURRENT HISTORY
CURRENT MEDICATION
CURRENT RX
CYTOLOGICAL SMEAR
D. PROBLEM SOLVING
D15
DATA ANALYSIS
DATA ENTRY
DATA ENTRY (TO BE FILLED IN MANUALLY)
DATE FIRST VISIT
DECISION
DELIVERY
DELIVERY DETAILS
DENGUE FEVER: ALTERED BODY TEMPERATURE
DENGUE FEVER: HEADACHE
DENGUE FEVER: ITCHINESS AND DISCOMFORT OVER PETECHIAE AND RASHNESS
DENGUE FEVER: JOINT AND MUSCLE PAIN
DENGUE FEVER: LACK OF KNOWLEDGE
DENGUE FEVER: POTENTIAL DEHYDRATION
DENGUE FEVER: POTENTIAL OF BLEEDING TENDENCY
DENGUE FEVER: VOMIT & NAUSEA
DENGUE FEVER: WORRY
DERMATOLOGY ASSESMENT NOTE - CUTANEOUS LUPUS ERYTHEMATOSUS DISEASE AREA AND SEVERITY INDEX (CLASI)
DERMATOLOGY: ALTERED BODY IMAGE
DERMATOLOGY: ANXIETY
DERMATOLOGY: CHANGES IN EYE MUCOSA
DERMATOLOGY: IMPAIRED SKIN INTEGRITY
DERMATOLOGY: ITCHYNESS
DERMATOLOGY: PAIN
DERMATOLOGY: POOR ORAL INTAKE
DERMATOLOGY: RISK FOR INFECTION
DESCRIPTION OF ANGIOGRAPHIC FINDING
DETAIL SCAN
DETAILED DESCRIPTION OF STUTTERING BEHAVIOR
DETAILED DESCRIPTION OF STUTTERING BEHAVIOR
DETAILS OF ACT
DETAILS OF CONTACT LENS
DETAILS OF FAMILY
DETAILS OF REFERRAL
DEVELOPMENT HISTORY
DEVELOPMENTAL HISTORY
DEVELOPMENTAL HISTORY (IF A CHILD)
DIABETIC MELLITUS: LACK OF KNOWLEDGE
DIABETIC MELLITUS: POTENTIAL DKA
DIABETIC MELLITUS: POTENTIAL HYPERGLYCAEMIA
DIABETIC MELLITUS: POTENTIAL HYPOGLYCAEMIA
DIABETIC MELLITUS: POTENTIAL PATIENT TO GET FOOT ULCER
DIADOCHOKINETIC RATE
DIAGNOSIS
DIAGNOSIS & SEVERITY
DIAGNOSIS (INPATIENT / OUTPATIENT)
DIAGNOSIS (INPATIENT)
DIAGNOSIS (OUTPATIENT)
DIAGNOSIS / PROBLEM
DIAGNOSIS ON DISCHARGE (PLEASE INCLUDE MAIN COURSE OF TREATMENT)
DIALYSIS ACCESS
DIET RECALL (FOOD ONLY)
DIETARY ASSESSMENT
DIETARY HISTORY (WHERE RELEVANT)
DIETARY INTAKE
DIETARY REQUIREMENT
DIGIT SPAN TEST
DISCHARGE
DISCHARGE
DISCHARGE DESTINATION/PLANS
DISCHARGE PLAN
DISEASES
DISMISSAL ARRANGEMENT
DISPLAY LAB RESULT
DISTANT VA
DISTANT VA
DOPPLER STUDY
DOUBLE DICHOTIC DIGIT TEST
DRUG HISTORY
DRUG OVERDOSE: ABDOMINAL PAIN
DRUG OVERDOSE: ANXIETY
DRUG OVERDOSE: DROWSINESS
DRUG OVERDOSE: SUICIDAL TENDENCY
DYSARTHRIA-ADULT
DYSFUNCTION
DYSFUNCTIONAL UTERINE BLEEDING: ALTERED SEXUAL ACTIVITY
DYSFUNCTIONAL UTERINE BLEEDING: ANEMIA
DYSFUNCTIONAL UTERINE BLEEDING: POTENTIAL OF HYPOVOLUMIC SHOCK
DYSPHAGIA CLINICAL RECORDS
DYSPIGMENTATION
E. LOGIC, REASONING, INFERENCE
EAR INFECTION
EATING BEHAVIOR
ECTOPIC PREGNANCY: ANXIETY
ECTOPIC PREGNANCY: KNOWLEDGE DEFICITS
ECTOPIC PREGNANCY: NAUSEA & VOMITING (POTENTIAL)
ECTOPIC PREGNANCY: PAIN
EDUCATION HISTORY
EDUCATIONAL INFORMATION
ELECTROCARDIOGRAPHY
ELECTROPHYSIOLOGY
EMERGENCY DEPARTMENT TO BE COMPLETED BY HUB
EMPLOYMENT HISTORY
ENCEPHALITIS: HYPERTHERMIA
ENCEPHALITIS: MENTAL DEFICIT
ENCEPHALITIS: MOBILITY DEFICIT
ENDOCRINE
ENDOMETRIAL SAMPLING
ENT EXAMINATION
ENT: ACTIVITY INTOLERANCE
ENTRANCE TEST
EPILEPSY: ANXIETY
EPILEPSY: KNOWLEDGE DEIFICIT (LACK OF KNOWLEDGE)
EPILEPSY: POTENTIAL COMPLICATION DURING FITTING
EPILEPSY: SELF - ISOLATION
ESTIMATED BLOOD LOSS
EXAMINATION
EXAMINATIONS
EXOMPHALUS: POTENTIAL INFECTION
EXTERNAL CEPHALIC VERSION (ECV) PROCEDURES
EXTERNAL CEPHALIC VERSION (ECV) PROCEDURES
EXTRAOCULAR MUSCLE ASSESSMENT
EYE CONTACT
EYE EXAMINATION
F. ORGANIZATIONAL THINKING
FAMILY AND SOCIAL HISTORY
FAMILY ENCOUNTER NOTE
FAMILY HISTORY
FAMILY INFORMATION
FAMILY MEMBERS
FEEDING ASSESSMENT
FEEDING HISTORY
FEES FINDINGS
FERTILITY HISTORY
FETAL BLOOD SAMPLING
FETOSCOPIC LASER COAGULATION
FETUS A
FIBRINOLYTIC_THERAPY
FINAL IMPRESSION
FINDINGS
FINDINGS
FIRST TRIMESTER SCAN FINDING
FITTING ASSESSMENT
FLUENCY
FLUID VOLUME DEFICIT
FLUID VOLUME EXCESS
FOLLOW UP
FOOD POISONING: DIARRHOEA
FOOD POISONING: FATIQUE
FOOD POISONING: RISK OF FLUIDS IMBALANCE; DEHYDRATION
FOOD POISONING: VOMITING
FORCEPS DELIVERY
FORMULATION
FULL EXAMINATION
FUNCTIONAL ACTIVITIES
FUNCTIONAL HISTORY
FUNCTIONAL INTELLIGIBILITY MEASURE
FUNCTIONAL STATUS
G. CALCULATION
GAIT
GAP IN NOISE
GASTRITIS: ABDOMEN DISCOMFORT, BEFORE OR AFTER EATING
GASTRITIS: EPIGASTRIC PAIN
GASTRITIS: LACK OF KNOWLEDGE
GASTRITIS: NAUSEA AND VOMITING
GASTROCHIASIS: LOSS OF FLUID AND HEAT
GASTROCHIASIS: POTENTIAL INFECTION
GASTROINTESTINAL
GENERAL APPEARANCE
GENERAL ASSESSMENT
GENERAL CONDITION
GENERAL EXAMINATION
GENERAL INFORMATION:
GENERAL MEDICINE: ABDOMINAL PAIN
GENERAL MEDICINE: INSUFFICIENT OF KNOWLEDGE
GENERAL MEDICINE: REDUCE APPETITE
GENTOURINARY/ FLUID/ ELECTROLYTE
GLASGOW COMA SCALE
GLAUCOMA: ACTIVITY INTOLERANCE
GLAUCOMA: ANXIETY
GLAUCOMA: CHANGE IN USUAL ACTIVITIES/ HOBBIES DUE TO ALTERED VISION
GLAUCOMA: DEFICIENT KNOWLEDGE (LEARNING NEED) REGARDING CONDITION, PROGNOSIS, TREATMENT, SELF-CARE NEEDS
GLAUCOMA: SENSORY/ PERCEPTUAL ALTERATION: VISUAL
GOALS
GONIO
GONIOSCOPY
GOUT: JOINT AND MUSCLE PAIN
GOUT: PONTENTIAL OF GETTING RENAL CALCULI
GULLIAN BARRE SYNDROME: CHANGES IN THE COPING MECHANISM
GULLIAN BARRE SYNDROME: MOBILITY DISORDER
GULLIAN BARRE SYNDROME: POTENTIAL INJURY
GULLIAN BARRE SYNDROME: RESPIRATORY DISORDER
GYNAECOLOGICAL EXAMINATION
GYNAECOLOGICAL EXAMINATION - CERVIX
GYNAECOLOGICAL EXAMINATION - EXTERNAL
GYNAECOLOGICAL EXAMINATION - OTHER
GYNAECOLOGICAL EXAMINATION - UTERUS
GYNAECOLOGICAL HISTORY
GYNAECOLOGY ULTRASOUND
H. READING & VISUAL PROCESSING
H.E.E.A.D.S.S.S ASSESSMENT
HABIT
HAEMATOLOGY
HAND OVER
HEADER
HEARING AID FINE TUNING
HEARING AID FITTING
HEARING AID TRIAL & PRESCRIPTION
HEARING AID VALIDATION
HEARING AID VERIFICATION
HEARING AND VISUAL ASSESSMENT
HEARING ASSESSMENT
HEARING DIAGNOSIS
HEARING HANDICAP
HEARING HISTORY
HEARING STATUS
HEART DISEASES IN PREGNANCY
HEMATOLOGY: ALTERED BODY IMAGE; ALOPECIA
HEMATOLOGY: ALTERED COMFORT : NAUSEA AND VOMITING
HEMATOLOGY: ALTERED CONFORT - PAIN
HEMATOLOGY: ALTERED ORAL MUCOUS MEMBRANE - MUCOSITIS
HEMATOLOGY: ANEAMIA
HEMATOLOGY: FEAR / ANXIETY
HEMATOLOGY: IMPAIRED BOWEL ELIMINATION - DIARRHEA
HEMATOLOGY: IMPAIRED URINARY ELIMINATION - HAEMORRHAGIC CYSTITIS / HAEMATURIA
HEMATOLOGY: PERIPHERAL NEUROPATHY
HEMATOLOGY: RISK OF BLEEDING
HEMATOLOGY: RISK OF INFECTION
HEPATOLOGY (HEPATITIS B & C): ANXIETY AND LACK OF KNOWLEDGE
HEPATOLOGY (HEPATITIS B & C): IMPAIRED SKIN INTEGRITY
HEPATOLOGY (HEPATITIS B & C): INBALANCE NUTRITION
HEPATOLOGY (HEPATITIS B & C): RESPIRATORY CHANGES
HEPATOLOGY (HEPATITIS B & C): RISK FOR DEFICIENT FLUID VOLUME
HEPATOLOGY (HEPATITIS B & C): RISK FOR INFECTION
HEPATOLOGY (HEPATITIS B & C): SITUATIONAL LOW SELF-ESTEEM
HESS CHART/BSV CHART
HISTORY
HISTORY DETAILS
HISTORY OF PRESENT COMPLAINTS
HISTORY OF PRESENT ILLNESS
HISTORY OF SPEECH THERAPY
HISTORY OF THE INCIDENT
HISTORY PAST OBSTETRICS / GYNAE
HISTORY/EXAMINATION (INCLUDING ELECTIVE ADMISSION FOR INTERVENTION)
HOME-BASED PROGRAM (HBP)
HOSPITAL PHASE
HYDROCEPHALUS: ALTERED COMFORT
HYDROCEPHALUS: EMOTIONAL DISTURBANCE OF PARENTS
HYDROCEPHALUS: POTENETIAL PRESSURE INJURY OVER THE HEAD
HYDROCEPHALUS: POTENTIAL OF INCREASING INTRACRANIAL PRESSURE
HYMEN INTACT
HYPEREMESIS: DECREASED APPETITE
HYPEREMESIS: NAUSEA AND VOMITTING
HYPERTENSION: ANXIETY
HYPERTENSION: HEADACHE
HYPERTENSION: INSOMNIA
HYPERTENSION: LACK OF KNOWLEDGE
HYPERTENSION: POTENTIAL OF PATIENT HAVING LOW BLOOD PRESSURE
HYPERTHERMIA
HYPOTHERMIA
HYSTEROSALPHINGOGRAM
I CONVERSATIONAL AND EXPOSITORY SPEECH
I. WRITING
ICU DISCHARGE PLAN & TRANSFER DOCUMENTATION
IDENTIFICATION OF VOCAL ABUSE
II AUDITORY COMPREHENSION
III VERBAL EXPRESSION
IMITATION
IMMEDIATE POST LASER TREATMENT COMPLICATION
IMMOBILITY
IMMUNIZATION
IMPAIRED GAS EXCHANGE
IMPEDANCE
IMPRESSION
IMPRESSION / DIAGNOSIS
IMPRESSION/ASSESSMENT
IN-HOSPITAL CLINICAL OUTCOMES
INCIDENT REPORTING
INEFFECTIVE COPING
INFANT-DRIVEN FEEDING SCALES
INFECTION CONTROL
INFECTIOUS DISEASE: DEHYDRATION
INFECTIOUS DISEASE: DIARRHOEA
INFECTIOUS DISEASE: POTENTIAL TO SPREAD (CONTAGIOUS)
INFERTILITY: ANXIETY
INFORMATION OF ABUSER
INJURY DETAILS
INSERTION OF CONTRACEPTIVE IMPLANT
INSERTION OF IUD
INSERTION OF VAGINAL PESSARY
INSTRUCTION
INSTRUCTIONS
INSTRUMENTAL DELIVERY
INSTRUMENTAL DELIVERY COMPLICATIONS
INTELLIGIBILITY
INTERRUPTED BREASTFEEDING
INTERVENTION
INTRA OPERATIVE ASSESSMENT
INTRA UTERINE DEATH: POTENTIAL DECREASE TISSUE PERFUSION
INTRA UTERINE DEATH: SADNESS
INTRAOCULAR PRESSURE(IOP)
INTRAUTERINE TRANSFUSION
INTRODUCTION
INVESTIGATION
INVESTIGATION RESULTS
IOL
IOL
IOP
ISOLATION PRECAUTION
ISSUE(S) OF CONCERN
IV - READING
J. PRAGMATICS & AFFECT
JAUNDICE: ALTERED SKIN COLOUR
JAUNDICE: EMOTIONAL DISORDERS OF PARENTS
KERATOMETRY
KNOWLEDGE DEFICIT
LAB INVESTIGATION
LABORATORY RESULT
LABOUR AND DELIVERY
LABOUR AND DELIVERY RECORD
LABOUR DETAIL
LACRIMAL SYSTEM
LANGUAGE COMPREHENSION
LANGUAGE OF SCHOOL AGED CHILDREN (7-18 YEARS OLD) NOTE
LANGUAGE USE
LAPAROSCOPY
LAPAROSCOPY AND DYE TEST
LAPORAN AWAL
LARYNGEAL FUNCTION
LASER ABILATION
LASER ABLATION
LEFT
LENS
LENS
LIDS
LIST OF TREATMENT PROVIDED
LISTENING AND UNDERSTANDING:
LISTENING ASSESSMENT
LISTENING ASSESSMENT COMPONENT
LONG TERM PLAN / FOLLOW UP
LONG-TERM MEMORY
LOUDNESS DISCOMFORT LEVEL
LOUDNESS MATCHING
LOW VISION ASSESSMENT
LOW VISION ASSESSMENT
LOW VISION DEVICES DELIVERY
LOW VISION FOLLOW-UP
MAKLUMAT PERAWATAN
MAKLUMAT PERAWATAN (Diisi oleh Pegawai Perubatan)
MAKLUMAT RUJUKAN
MALARIA: BODY TEMPERATURE DISTURBANCE
MALARIA: POTENTIAL OF SPREADING
MANAGEMENT
MANAGEMENT AND NURSING CARE
MANAGEMENT PLAN
MATCHING
MATERIAL SENT OT PATHOLOGY
MATERNAL CONDITION - POST DELIVERY
MATERNAL HISTORY
MEASUREMENT
MEASUREMENT
MEDICAL ALERT
MEDICAL AND SURGICAL HISTORY
MEDICAL AND SURGICAL HISTORY WITH POSIBBLE ADVERSE EFFECTS ON FERTILITY
MEDICAL CERTIFICATE / LIGHT DUTY
MEDICAL HISTORY
MEDICATION
MEDICATION ADMINISTERED
MEDICATION ON DISCHARGE
MEDICO LEGAL SPECIMENS
MENINGITIS: HYPERTHEMIA
MENINGITIS: POOR CEREBRAL TISSUE PERFUSSION
MENINGITIS: POTENTIAL INFECTION
MENINGITIS: POTENTIAL INJURY
MENSTRUAL AND OVULATION HISTORY
MENSTRUAL HISTORY
MENTAL STATE EXAMINATION
MENTAL STATUS
MINIMUM MASKING LEVEL
MISSED AND INCOMPLETE ABORTION: ANXIETY
MISSED AND INCOMPLETE ABORTION: KNOWLEDGE DEFICIT
MISSED AND INCOMPLETE ABORTION: NAUSEA & VOMITING (POTENTIAL)
MISSED AND INCOMPLETE ABORTION: PAIN
MISSED AND INCOMPLETE ABORTION: POTENTIAL HPOVOLUMIC SHOCK
MISSED AND INCOMPLETE ABORTION: POTENTIAL OF HEAVY BLEEDING
MODE OF DELIVERY
MODIFIED RANKIN SCALE (MRS)
MODIFIED RANKING SCALE (mRS)
MOLAR PREGNANCY: ANXIETY
MOLAR PREGNANCY: EMOTIONAL DISTURBANCE DUE TO ALTERED BODY IMAGE
MOLAR PREGNANCY: KNOWLEDGE DEFICITS
MOLAR PREGNANCY: POTENTIAL DEHYDRATION
MONITORING AND EVALUATION
MONITORING EVALUTION
MORPHOEA /SCLERODERMA
MOTHER
MOTHERS DETAILS
MOTOR FUNCTION
MUCOUS MEMBRANE
MUCOUS MEMBRANE
MULTIPLE PREGNANCY DESCRIPTION
MUSCLE TONE
MUSCULOSKELETAL
MUSCULOSKELETAL SYSTEM
MYCOSIS FUNGOIDES
NASOMETER ANALYSIS
NEAR VA
NEONATAL HISTORY
NEONATAL PERIOD - FIRST 28 DAYS (ONLY FOR NEONATES
NEUROLOGICAL SYSTEM
NEUROLOGICAL TESTS
NEUROMUSCULAR ELECTRICAL STIMULATION PROCEDURE NOTE
NEXT SESSION PLAN
NON-NUTRITIVE SUCKING / SWALLOW
NURSING ASSESSMENT
NURSING CARE PLAN
NUTRITION ASSESSMENT OF DIET INTAKE
NUTRITION DIAGNOSIS
NUTRITION DIAGNOSIS (PROBLEM, ETIOLOGY, SIGN & SYMPTOM)
NUTRITION DIAGNOSIS (PROBLEM,ETIOLOGY,SIGN & SYMPTOM)
NUTRITION FOCUSED PHYSICAL FINDINGS
NUTRITION INTERVENTION
NUTRITION INTERVENTION (PLAN) & MONITORING AND EVALUATION
NUTRITION INTERVENTION (PLAN) & MONITORING AND EVALUATION
NUTRITION RELATED BIOCHEMISTRY
NUTRITIONAL HISTORY
OBJECTIVE
OBSERVATION
OBSERVATION & PATHOPHYSIOLOGY
OBSTETRIC/MENSTRUAL HISTORY
OBSTETRICS HISTORY
OBSTETRICS LMP DETAILS
OCCUPATIONAL HISTORY
OCCUPATIONAL INFORMATION
OCCUPATIONAL THERAPY HISTORY
OCCUPATIONAL THERAPY PROGRESS NOTE
OCULAR EXAMINATION
OFFICE HYSTEROSCOPY
ON SET
ONSET
OPERATION ORIF, BSSO SURGICAL REMOVAL: KNOWLEDGE DEFICIT
OPERATIVE PROCEDURE
ORAL INTAKE (CURRENT / DIET HISTORY)
ORAL MOTOR EXAMINATION
ORAL-MOTOR EXAMINATION
ORAL-MOTOR FUNCTION
ORL EXAMINATION
ORL FINDINGS
OROMOTOR MOVEMENT
OSCC ADMINISTRATOR
OSCC TEAM
OTHER
OTHER DIAGNOSIS
OTHER FACTORS WITH POSSIBLE ADVERSE EFFECTS ON FERTILITY
OTHER FACTORS WITH POSSIBLE EFFECTS ON FERTILITY
OTHER HISTORY
OTHER INDICATION
OTHER INFORMATION
OTHER INFORMATION FROM MEDICAL OFFICER
OTHER PARAMETERS
OTHER PROBLEM IN OBSTETRICS
OTHER PROCEDURE
OTHER PROFESSIONALS' INVOLVEMENT
OTHER SYSTEMS
OTHERS
OTOLOGIC HISTORY
OTORHINOLARYNGOLOGY
OTOSCOPIC EXAMINATION
OUTCOME
OUTCOME AT DISCHARGE
OUTCOME MEASURE
OUTCOME MEASURE EVALUATION
OUTREACH SCREENING
OVERALL SESSION OBSERVATION
OXYGEN DELIVERY DURING PROCEDURAL SEDATION
PAEDIATRIC HISTORY
PAEDIATRICS LANGUAGE DEVELOPMENT
PALLIATIF CARE: ANXIETY
PALLIATIF CARE: CHANGES IN RESPITATORY PATTERN
PALLIATIF CARE: ELECTROLYTES IMBALANCE
PALLIATIF CARE: FEVER
PALLIATIF CARE: INSOMNIA
PALLIATIF CARE: LIMITED MOBILITY
PALLIATIF CARE: NAUSEA & VOMITING
PALLIATIF CARE: POTENTIAL FOR IMPAIRED ELIMINATION (CONSTIPATION)
PALLIATIF CARE: POTENTIAL SURGICAL WOUND INFECTION
PART 1: ADMISSION INFORMATION
PART 2: NURSING ASSESSMENT
PART 3: FALL RISK ASSESSMENT (MODIFIED MORSE FALL SCALE)
PART 3: RISK ASSESSMENT
PART 4: PSYCHOSOCIAL HISTORY
PAST HISTORY
PAST MEDICAL HISTORY
PAST OBSTETRIC HISTORY
PAST OBSTETRICS HISTORY
PAST SURGICAL HISTORY
PATIENT ASSESSMENT
PATIENT DATA
PATIENT DEMOGRAPHIC
Patient Details
PATIENT HISTORY
PATIENT HISTORY
PATIENT INFORMATION
PATIENT MOTIVATION
PATIENTS ACHIEVEMENT
PATIENTS PERCEPTION OF OWN VOICE
PATIENTS PERFORMANCE
PATIENTS PROGRESS
PELVIC EXAMINATION
PELVIC ORGAN
PENETRATION / ASPIRATION SCALE 1 - 8 (ROSENBEK, 1996
PERANCANGAN PERAWATAN
PERANCANGAN PERAWATAN (Diisi oleh Pegawai Perubatan)
PERCUTANEOUS TRANSHEPATIC BILIARY DRAIN (PTBD): DEFICIENT OF KNOWLEDGE RELATED TO CARE OF PTBD
PERCUTANEOUS TRANSHEPATIC BILIARY DRAIN (PTBD): IMPAIRED SKIN INTEGRITY
PERCUTANEOUS TRANSHEPATIC BILIARY DRAIN (PTBD): KNOWLEDGE DEFICIENT OF WOUNDS CARE AFTER DISCHARGE
PERCUTANEOUS TRANSHEPATIC BILIARY DRAIN (PTBD): PAIN
PERCUTANEOUS TRANSHEPATIC BILIARY DRAIN (PTBD): RESPIRATORY CHANGES
PERCUTANEOUS TRANSHEPATIC BILIARY DRAIN (PTBD): RISK FOR INFECTION
PERFORMED BY
PERFORMING STAFF
PERIHAL PENJAGA
PERIHAL PENJAGA (Diisi oleh Jururawat)
PERIHAL PESAKIT
PERIHAL PESAKIT (Diisi oleh jururawat)
PERSONAL AND SOCIAL HISTORY
PERSONAL DETAILS
PERSONAL HISTORY
PERSONAL PARTICULARS
PHARMALOGICAL THERAPY (USED / GIVEN DURING ADMISSION)
PHOTOGRAPH
PHYSICAL ASSESSMENT
PHYSICAL ASSESSMENT (CHECK BOXES PERTAINING TO PATIENT)
PHYSICAL DEVELOPMENT
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION (SYSTEMIC)
PHYSICAL EXAMINATION - CHEST PAIN
PHYSICAL EXAMINATION AND ASSESSMENT
PHYSICAL FINDINGS
PHYSIOTHERAPY IMPRESSION
PHYSIOTHERAPY REFERRAL DETAILS
PITCH MATCHING
PITCH PATTERN SEQUENCE TEST (PPST)
PLAN
PLAN OF CARE
PLAN OF CARE : CHOOSE TOP 3 PRIORITIES FOR PLAN OF CARE
PLAN OF TREATMENT
PLAN/PROGRESS
PNEUMONIA: DIFFICULTY IN BREATHING, TACHYPNOEA
PNEUMONIA: FEVER
PNEUMONIA: INCREASE IN SECRETION
PNEUMONIA: LOST OF APPETITE
POST OPERATIVE ASSESSMENT
POST OPERATIVE LSCS: NAUSEA & VOMITING
POST OPERATIVE LSCS: PAIN
POST OPERATIVE LSCS: POTENTIAL OF BLEEDING
POST OPERATIVE LSCS: POTENTIAL OF INFECTION
POST OPERATIVE LSCS: RISK OF HYPOVOLUMIC SHOCK
POST PARTUM ORDERS
POST SURGICAL INTERVENTION: ACUTE PAIN
POST-SEDATION ASSESSMENT BY DOCTOR
POSTERIOR SEGMENT
POSTNATAL COURSE
POSTOPERATIVE PAIN: CONSTIPATION
POSTOPERATIVE PAIN: RISK FOR INEFFECTIVE BREATHING PATTERN
POSTOPERATIVE PAIN: SEVERE PAIN EVIDENCE BY SLEEP PATTERN DISTURBANCE
POTENTIAL FOR INFECTION
PPH: ANEMIA
PPH: ANXIETY
PPH: EXCESSIVE BLEEDING (> 500MLS IN 24 HRS)
PPH: FLUIDS DEFICITS
PPH: LETHARGY
PPH: POTENTIAL OF COMPLICATIONS SECONDARY TO PER VAGINAL BLEEDING
PPH: POTENTIAL OF HYPOVOLUMIC SHOCK
PRAGMATIC LANGUAGE-PAEDIATRICS
PRE HOSPITAL CARE
PRE HOSPITAL PHASE TREATMENT (OTHER THAN PHC)
PRE PROCEDURE HISTORY
PRE-SCOPE HISTORY
PRE-SEDATION ASSESSMENT BY NURSE
PREFEEDING OBSERVATIONS
PREGNANCY
PRELIMINARY EXAMINATION AND TRIAL FITTING
PRELIMINARY REPORT
PRELIMINARY TEST
PREMATURE WITH RDS: IMPAIRED GAS EXCHANGE
PREMORBID HISTORY
PRESENT HISTORY
PRESENT PREGNANCY
PRESENT PREGNANCY (LATEST OBSTETRIC ENCOUNTER)
PRESENTING PROBLEMS
PREVIOUS INTERVENTION
PREVIOUS INVESTIGATION
PREVIOUS INVESTIGATION RESULTS
PREVIOUS INVESTIGATIONS AND TREATMENTS FOR INFERTILITY
PRIMARY SURVEY
PROBLEM
PROBLEM IDENTIFICATION
PROBLEM LIST
PROCEDURAL COMPLICATION
PROCEDURE
PROCEDURE DETAILS
PROCEDURE REPORT
PROCEDURES AND TREATMENT
PROCEDURES PERFORMED DURING ADMISSION (INCLUDING PACEMAKER INSERTION) - IF DONE
PROFESSIONAL EVALUATIONS COMPLETED
PROGNOSIS
PROGNOSIS&PATIENT/CAREGIVERS EXPECTATION
PROGRESS
PROSODY / RATE
PROVISIONAL DIAGNOSIS
PSORIASIS
PSORIATIC ARTHRITIS
PSYCHIATRIC
PSYCHIATRIC 2
PSYCHOSOCIAL HISTORY
PURPOSE
PURPOSE OF REFERRAL
RADIOTHERAPY AND ONCOLOGY: ACTIVITY INTOLERANCE
RADIOTHERAPY AND ONCOLOGY: ACUTE PAIN
RADIOTHERAPY AND ONCOLOGY: ACUTE RAFIATION SKIN REACTIONS (DRY/MOIST)
RADIOTHERAPY AND ONCOLOGY: ANTICIPATORY GRIEVING
RADIOTHERAPY AND ONCOLOGY: ANXIETY
RADIOTHERAPY AND ONCOLOGY: CHEMOTHERAPY EXTRAVATION
RADIOTHERAPY AND ONCOLOGY: DISTURBED SLEEP PATTERN
RADIOTHERAPY AND ONCOLOGY: FATIQUE
RADIOTHERAPY AND ONCOLOGY: FEAR ANXIETY
RADIOTHERAPY AND ONCOLOGY: HEMORRHAGIC CYSTITIS
RADIOTHERAPY AND ONCOLOGY: NUTRITION: LESS THAN BODY REQUIREMENTS
RADIOTHERAPY AND ONCOLOGY: ORAL MUCUSITIS
RADIOTHERAPY AND ONCOLOGY: PERIPHERAL NEUROPATHY
RADIOTHERAPY AND ONCOLOGY: RISK FOR ALTERED SEXUALITY PATTERNS
RADIOTHERAPY AND ONCOLOGY: RISK FOR CONSTIPATION /DIARRHEA
RADIOTHERAPY AND ONCOLOGY: RISK FOR FALLS
RADIOTHERAPY AND ONCOLOGY: RISK FOR FLUID VOLUME DEFICIT
RADIOTHERAPY AND ONCOLOGY: RISK FOR INFECTION
RADIOTHERAPY AND ONCOLOGY: RISK NAUSEA AND VOMITING
RADIOTHERAPY AND ONCOLOGY: RISK OF ANEMIA
RADIOTHERAPY AND ONCOLOGY: RISK OF CHEMOTHERAPY EXTRAVASATION
RADIOTHERAPY AND ONCOLOGY: RISK OF HAIR LOSS OR ALOPECIA OR HAIR THINNING
RADIOTHERAPY AND ONCOLOGY: RISK OF PRESSURE ULCER / DECUBITUS ULCER
RADIOTHERAPY AND ONCOLOGY: SITATUINAL LOW SELF-ESTEEM
RAWATAN SUSULAN YANG DIPERLUKAN
RAWATAN SUSULAN YANG DIPERLUKAN
RE
READING
REASON FOR DISCHARGE
REASON FOR REFERRAL
RECOMMENDATION / PLAN
RECOMMENDATIONS
RECORD OF PATIENT'S PERFORMANCE
RECORD OF PATIENTS PERFORMANCE / PROGRESS
RECORD OF PATIENTS PERFORMANCE / PROGRESS
RECORD RESUSCITATION AND STABILIZATION
RED FLAGS FOR PAEDIATRICS COMMUNICATION SKILL
REFER DETAILS
REFERRAL
REFERRAL
REFERRAL DETAILS
REFERRAL INFORMATION
REFLEXES
REFLEXES/BRISKESS
REFLEXES/BRISKNESS
REFRACTION FINDINGS
REHAB TEAM
RELATED OBSERVATIONS
RELEVANT INVESTIGATIONS
REMARKS
REMOVAL OF CONTRACEPTIVE IMPLANT
REMOVAL OF IUD
REPERFUSION THERAPY / MANAGEMENT
REPLANTATION PATIENTS: ANXIETY
REPLANTATION PATIENTS: LACK OF KNOWLEDGE
REPLANTATION PATIENTS: POOR APPETITE
REPLANTATION PATIENTS: POTENTIAL CHANGE OF FINGER COLOR (PALE / BLUE)
REPLANTATION PATIENTS: POTENTIAL HYPOXOLEMIC SHOCK
REPLANTATION PATIENTS: POTENTIAL INFECTIONS
REPLY DETAILS
REPORT
REPORTS
REQUIRED SERVICE/S
RESIDUAL INHIBITION
RESOLVED PROBLEM
RESONANCE-ADULT
RESPIRATION
RESPIRATORY
RESPIRATORY PROBLEM: ACTIVITY INTOLERANCE
RESPIRATORY PROBLEM: ALTERED FAMILY PROCESSES/COPING
RESPIRATORY PROBLEM: GAS EXCHANGE, IMPAIRED
RESPIRATORY PROBLEM: INEFFECTIVE AIRWAY CLEARANCE
RESPIRATORY PROBLEM: INEFFECTIVE BREATHING PATTERN
RESPIRATORY PROBLEM: RISK FOR INFECTION
RESPIRATORY PROBLEM: RISK OF FLUID VOLUME DEFICIT
RESPONSE TEAM
RESULT
RESULTS REVIEW
RESUSCITATION
RETROVIRAL DISEASE: DIARRHOEA
RETROVIRAL DISEASE: LACK OF KNOWLEDGE
RETROVIRAL DISEASE: LOSS OF APPETITE
RETROVIRAL DISEASE: NAUSEA AND VOMIT
RETROVIRAL DISEASE: SKIN INTEGRITY DISORDER, PETECHIAE AND RASHNESS
RHEUMATOID ARTHRITIS
RHEUMOTOLOGY: ALTERED BODY IMAGE
RHEUMOTOLOGY: DEFICIENT KNOWLEDGE
RHEUMOTOLOGY: HEADACHE
RHEUMOTOLOGY: INEFFECTIVE BREATHING PATTERN
RHEUMOTOLOGY: INEFFECTIVE PERIPHERAL TISSUE PERFUSION
RHEUMOTOLOGY: JOINT & MUSCLE PAIN
RHEUMOTOLOGY: LIMITED MOBILITY
RHEUMOTOLOGY: NAUSEA AND VOMIT
RHEUMOTOLOGY: PAIN
RHEUMOTOLOGY: PHOTOSENSITIVITY
RHEUMOTOLOGY: SKIN INTEGRITY DISORDER, PETECHIAE AND RASHNESS
RIGHT
RISK ASSESSMENT
SAMPLER
SCAN TEAM MEMBERS INCHARGE
SCARRING OF SCALP
SCENE ASSESSMENT
SCORE:
SCORING
SCREENING
SECOND / THIRD TRIMESTER SCAN FINDING
SECTION 1: GENERAL INFORMATION
SECTION II : HISTORY/EXAMINATION (INCLUDING ELECTIVE ADMISSION FOR INTERVENTION)
SECTION III : RELEVANT INVESTIGATIONS
SECTION IV : DIAGNOSIS ON DISCHARGE (PLEASE INCLUDE MAIN COURSE OF TREATMENT)
SECTION V : PROCEDURES PERFORMED DURING ADMISSION (INCLUDING PACEMAKER INSERTION) - IF DONE
SECTION VI : MEDICATION ON DISCHARGE
SECTION VII : LONG TERM PLAN/ FOLLOW UP
SEDATION CARE PLAN - ASSESSMENT BY NURSE
SEDATION CARE PLAN - POST –SEDATION ASSESSMENT BY DOCTOR
SEDATION CARE PLAN - PRE-PROCEDURAL SEDATION ASSESSMENT BY DOCTOR
SEDATION CARE PLAN - PRE-SEDATION ASSESSMENT BY DOCTOR
SEDATION DOCUMENTATION
SELF-CARE DEFICIT
SEMEN ANALYSIS
SENSORY
SENSORY SYMPTOMS
SESSION CLINICAL NOTES
SESSION CLINICAL NOTES
SESSION DETAILS
SESSION NOTES (ONE-HOUR SESSION)
SEVERITY
SEVERITY RATING
SEXUAL HISTORY
SEXUAL HISTORY (WHERE RELEVANT)
SEXUAL HISTORY OF BOTH PARTNERS
SHORT-TERM MEMORY
SIDE EFFECTS
SIGNATURE (BY ETD DOCTOR)
SIGNATURE (DOCTOR O&G)
SIGNATURE (DOCTOR PAEDIATRIC)
SIGNATURE (DOCTOR SURGERY)
SIGNATURES
SLE: SKIN INTEGRITY DISORDERS (INFLAMMATORY: VASOCONSTRICTION)
SLEEP HISTORY
SLIT-LAMP
SNAP II -PE SCORE
SOCIAL AND FAMILY HISTORY
SOCIAL BACKGROUND
SOCIAL HISTORY
SODOMY
SOFT TISSUE INJURY OR MAJOR SURGERY: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
SOFT TISSUE INJURY OR SURGICAL PROCEDURE: IMPAIRED ORAL MUCOUS MEMBRANE
SPECIAL TESTS
SPECIFIC QUESTIONS
SPECULUM EXAMINATION / EXAMINATION IN STANDING POSITION
SPEECH BEHAVIOUR
SPEECH DEVELOPMENT
SPEECH INTELLIGIBILITY RATING (SIR)
SPEECH PRODUCTION
STATUS BEFORE EVENT
STIMULUS
STRATEGIES TO ENHANCE DEVICE USE IN CLASSROOM
STRUCTURAL OBSERVATION
SUBJECTIVE
SUBTEST 1 : DIADOCHOKINETIC RATE
SUBTEST 2 : INCREASING WORD LENGTH
SUBTEST 3 : LIMB APRAXIA AND ORAL APRAXIA
SUBTEST 4 : RESPONSE RATE AND UTTERANCE TIME FOR MULTISYLLABIC WORDS
SUBTEST 5 : REPEATED TRIAL TEST
SUBTEST 6 : ARTICULATION FEATURES INVENTORY
SUMMARIES OF PATIENT PROGRESS
SUMMARY
SUMMARY AND COMMENTS
SUMMARY AND RECOMMENDATION
SUMMARY OF FINDINGS
SWALLOWING PROBLEMS
SYMBOL SYSTEM
SYMBOLIC PLAY
SYMPTOMS
SYSTEM RECOMMENDATION
SYSTEMIC
SYSTEMIC EXAMINATION
SYSTEMIC LUPUS ERYTHEMATOSUS
SYSTEMIC PROBLEM
SYSTEMIC REVIEW
SYSTEMIC REVIEW
SYSTEMIC SCLEROSIS
TERMINATION OF PREGNANCY (TOP)
THERAPEUTIC MANOEUVRE
THERAPEUTIC MANOEUVRES & EFFICACY
THERAPEUTIC MANOEUVRES TRIALLED & EFFICACY
THIRD STAGE MANAGEMENT
THYPHOID: DEHYDRATION
THYPHOID: DIARRHOEA
THYPHOID: FEVER
THYPHOID: POTENTIAL OF INFECTIOUS TO OTHERS PERSON
THYROID: ANXIETY
THYROID: INSOMNIA
THYROID: WEIGHT LOSS
TINNITUS
TINNITUS MANAGEMENT
TINNITUS TREATMENT
TO BE FILLED BY STAFF/PHYSIOTHERAPIST
TOTAL HYSTERECTOMY & SALPHINGO-OOPHERECTOMY (TAHBSO): ANXIETY
TOTAL HYSTERECTOMY & SALPHINGO-OOPHERECTOMY (TAHBSO): LIMITED ACTIVITIES
TOTAL HYSTERECTOMY & SALPHINGO-OOPHERECTOMY (TAHBSO): PAIN
TOTAL SCORE
TRACHEAL OESOPHAGEAL FISTULA: POTENTIAL ASPIRATION
TRAUMA ASSESSMENT
TREATENED ABORTION: ANXIETY
TREATENED ABORTION: KNOWLEDGE DEFICITS
TREATENED ABORTION: PAIN
TREATMENT
TREATMENT AND AFTER CARE
TREATMENT CONSENT FORM
TREATMENT PLAN(GOALS AND ACTIVITIES)
TUBERCULOSIS: HAEMOPTYSIS
TUBERCULOSIS: LACK OF KNOWLEDGE
TUBERCULOSIS: POTENTIAL OF SREADING - RISK OF INFECTIOUS TO OTHERS PERSON
TUBERCULOSIS: PROGRESSIVE COUGH
TUBERCULOSIS: PROLONG FEVER
TURN TAKING
TYPE OF AMPLIFICATION
TYPE OF PHOTOTHERAPY
TYPE OF PROCEDURE
TYPE OF TREATMENT
ULTRASONOGRAPHY OF PELVIS
ULTRASOUND FINDINGS
URODYNAMICS
UROGENITAL EXAMINATION
UTERIN INVERSION: BLEEDING
UTERIN INVERSION: POTENTIAL OF HYPOVOLUMIC SHOCK
UTERIN RUPTURE: ANXIETY
UTERIN RUPTURE: POTENTIAL OF HYPOVOLUMIC SHOCK
UTERIN RUPTURE: RISKS OF HYPOXIA TO FETUS
V - WRITING
VACUUM DELIVERY
VAGINAL BREECH DELIVERY
VAGINAL DELIVERY SUMMARY
VAGINAL HYSTERECTOMY: ANXIETY
VAGINAL HYSTERECTOMY: KNOWLEDGE DEFICITS
VAGINAL HYSTERECTOMY: PAIN
VAGINAL HYSTERECTOMY: POTENTIAL OF INFECTION
VAGINITIS, VULVITIS & BARTHILON CYST: DISCOMFORT
VAGINITIS, VULVITIS & BARTHILON CYST: KNOWLEDGE DEFICITS
VALVES
VASCULITIS
VELOPHARYNGEAL PORT
VERBAL EXPRESSION
VFSS RESULTS
VISUAL ACUITY AND REFRACTIVE STATUS
VISUAL FIELD
VITAL SIGNS
VITAL SIGNS
VITAL SIGNS & OTHER OBSERVATIONS
VITAL SIGNS / EXAMINATION
VITAL SIGNS AND OTHER OBSERVATIONS
VITALS PRIOR TO PROCEDURAL SEDATION
VITILIGO
VOCABULARY / SYMBOL USE
VOICE PRODUCTION
VOICE QUALITY EVALUATION
VULVA
WRITING
15544
15546
13009
11148
11396
11400
11403
11405
1
8293
13085
15508
15539
6407
6408
81
8258
82
83
84
10866
85
8388
86
87
15314
88
89
15313
90
91
14131
14125
13473
15538
13460
8253
8254
13128
268
324
12323
12324
8328
9364
109
12749
11882
11900
11913
11924
11935
206
204
13548
208
207
209
210
6419
211
212
6398
6399
6400
2
6401
3
4
5
6
7
9365
9366
9367
13560
8
110
12750
214
215
9404
9361
216
29
218
6420
315
219
8251
220
221
222
223
224
264
263
225
226
227
12464
8547
10446
228
229
8447
230
8445
231
232
233
8543
234
235
236
237
238
239
240
241
242
8449
243
244
245
246
247
8541
248
8566
249
8556
250
251
252
253
12636
254
13242
13126
12822
12639
8600
13345
255
256
257
258
5954
14579
259
13250
11986
260
261
8927
112
9439
11892
11903
11916
11927
11938
265
266
30
267
269
8216
270
271
272
273
274
14588
2017
275
276
277
278
14
22
15552
279
280
281
14589
3134
282
283
284
285
23
10483
286
287
11580
2295
14590
288
289
290
291
292
24
11893
11904
11917
11928
11942
9440
293
14591
294
295
296
297
298
299
300
301
302
14593
25
8928
31
303
304
305
306
307
5952
14594
15
9441
11894
11906
11918
11929
11943
308
309
310
14595
3135
26
311
312
14596
5949
313
14597
314
11895
11907
11919
11930
11944
9442
14598
9368
8419
111
262
12751
9369
8417
11581
11582
11583
316
317
6421
6410
318
8256
319
9
113
12752
14592
9405
9362
9375
321
322
6422
323
13549
325
376
8221
8225
8208
326
327
8252
365
366
328
329
330
331
332
12213
333
334
8454
335
336
337
338
339
340
341
13251
2018
14580
342
8548
343
344
12637
345
8450
346
347
348
349
8542
350
351
352
8544
353
8567
8557
354
355
13127
12823
13346
356
357
12640
8601
13243
12465
358
359
360
361
362
8734
8735
8736
11987
11988
363
8535
364
8929
367
32
14599
2021
16
27
368
369
5948
14600
14601
14602
5461
8617
6423
13526
8854
5961
14603
6424
15305
9443
11896
11909
11920
11931
11945
370
6425
6426
14604
3136
11
5242
14605
14606
5240
5241
14607
14608
1546
9370
9360
114
12753
8420
11584
371
372
373
6427
10403
6411
374
8257
375
10
377
115
10484
378
9406
9376
9363
6428
379
415
418
419
8226
8209
380
8222
381
382
383
384
385
386
387
388
389
390
391
8456
12824
392
13129
393
13244
14581
2016
8558
13252
12466
8451
394
395
396
12214
397
398
399
400
401
8549
402
8545
403
13347
404
405
406
407
408
409
410
411
14609
17
9444
11897
11910
11921
11932
11946
6243
14610
14611
412
14612
5953
13626
14613
5459
4709
14614
14615
1543
11898
11911
11922
11933
11947
9445
14616
6173
14617
1544
14618
5462
116
9371
413
12325
9352
416
417
6429
6402
117
12754
12755
118
11890
11901
11914
11925
11936
10485
9377
6430
421
6431
423
422
8210
424
8227
8223
425
426
427
428
429
430
431
432
433
434
435
436
437
14582
438
439
13253
440
12467
8452
441
442
12215
443
444
445
8550
446
447
13348
448
13245
449
450
11989
8755
8756
8759
451
5368
14619
18
14620
3687
14621
1545
11899
11912
11923
11934
11948
9446
14622
5958
14623
14624
5236
5489
14625
14626
5235
2301
14627
14628
4596
9372
452
6403
12756
119
9378
457
6432
453
33
455
11579
456
482
8211
8228
8224
459
460
461
12216
8455
462
463
464
458
34
465
14583
466
8453
467
468
13246
8448
469
470
471
472
473
474
13349
475
476
477
478
479
8552
480
8568
8671
6433
6434
12
481
9373
483
6404
120
12757
10486
9379
484
485
486
487
6435
488
489
490
8212
491
12937
8229
492
493
494
495
496
497
498
499
500
13247
501
502
503
504
505
506
14584
5950
507
19
508
6405
509
121
12758
11891
11902
11915
11926
11937
122
9380
8571
525
510
8213
511
512
513
514
515
516
517
518
14585
2728
519
520
521
522
523
524
13248
6436
6437
13
6406
123
12759
9381
526
541
8214
527
528
529
530
531
532
2733
14586
533
534
535
536
537
538
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134
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15532
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13813
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15280
1853
1854
14516
14517
14518
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136
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1856
11484
11485
1857
9043
1858
1859
1860
1861
6824
14520
1862
1863
1864
1865
1866
1867
1868
1869
1870
1871
1872
13829
1875
1876
9081
1877
1873
1874
13503
12388
14874
15016
15013
15002
15071
8710
1879
1880
1881
1882
1883
1884
8510
1885
1886
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6825
6826
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1888
11194
1889
1890
13267
6828
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15301
14208
14211
14210
14209
14212
6830
1891
11664
11671
11675
11676
6831
15292
1892
10459
1893
40
12632
1895
1896
1897
1898
1899
11715
1900
8507
1901
15329
1902
1903
1904
6832
1905
9201
1906
1907
6833
6834
6835
6836
6837
6838
6839
6840
15400
15398
6841
6842
8728
6843
15325
10526
10527
10528
1908
1909
12486
12484
12485
12483
12482
6844
1910
1911
13993
1912
1913
1914
6396
6381
6846
1915
1916
1917
1918
1919
9184
12435
10306
13233
1920
1921
1922
1924
8613
10286
15386
8690
8691
8689
14924
1925
1926
1927
1928
1929
1930
1931
9200
14040
1932
1933
8422
1934
1935
1936
1937
8423
1938
9345
13053
11066
11167
12930
12931
1939
12990
137
1940
1941
1942
1943
1944
1945
6847
1946
11398
11399
11979
6848
10316
6849
1947
1948
1949
1950
1951
13004
10166
9234
1952
1953
15506
1954
1955
13600
14475
41
1956
8320
1957
13446
1958
10052
10024
1959
10707
1960
1961
1962
1963
10550
1964
6850
9455
8639
8829
14828
12365
12337
1965
12343
12341
11974
11968
11971
1966
1967
11875
1968
1969
9132
1970
1971
1972
6851
6852
1973
8886
10790
10793
14461
15364
10159
12673
6853
6854
6855
1974
11690
11142
11873
11874
13026
1975
1976
1977
11802
14529
9139
8263
13431
8268
1978
1979
1980
1981
1982
1983
1984
15282
15283
12939
12974
1985
1986
1987
1988
10899
6375
1989
1990
1991
1992
6856
1993
1994
13591
42
13311
13313
13393
13383
10812
1995
1996
10806
13377
10293
1997
1998
8871
8865
8870
1999
8861
8872
8868
43
9258
9255
2000
2001
2002
2003
2004
14130
8866
8862
8867
14127
8869
8873
8395
2005
2006
13430
2007
2009
2010
2011
15541
2012
10546
13457
13396
2013
9100
2014
2015
11546
2020
8874
8875
10817
13388
9248
9249
8401
2022
2023
2024
10983
8397
2025
2026
2027
6857
2028
8259
13533
12770
11280
2029
2030
15464
6858
11462
8753
11939
11940
11941
8747
8748
13535
8751
8746
8741
8750
8749
14080
8752
8932
6390
2031
6363
2032
2033
138
10116
6859
139
2034
6860
2035
2036
2037
2038
13970
13971
13972
13973
13974
13975
13976
71
6861
2041
2042
2043
2044
2040
2045
13052
11063
6862
12258
8189
8318
15403
15404
15402
15528
15377
15017
2046
2047
15450
2048
15411
15417
2049
2050
12440
12446
12450
11649
11650
11651
2051
10038
2052
2053
2054
2055
2056
2057
2058
2059
12626
2060
6863
2061
2062
2063
14214
14216
14215
14217
8128
2064
2065
2066
13722
8305
8786
2067
2068
6864
6865
6866
2069
2070
2071
6867
2072
2073
2074
140
11034
11346
11861
2075
13255
13256
13257
13258
13259
13425
13426
13427
13627
13628
13629
13630
13631
13632
13633
13634
13635
13636
13637
13638
13639
13640
13641
13642
13643
2076
2077
6868
13152
13153
13154
13155
13156
2078
10579
2079
141
14453
11057
2080
6869
6870
6871
2081
2082
6872
9438
2083
2084
6873
2085
2086
6874
11056
2087
11182
8300
6875
2088
13723
13724
13725
13726
13727
13728
13729
13730
13731
2089
2090
8389
2091
2092
6876
2093
8628
2094
6877
2095
2096
6878
13501
2097
6879
10563
2098
2099
10741
11863
2100
2101
13169
6880
14845
2102
14074
2103
15418
2104
6881
15405
2105
6882
11688
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12360
7937
5811
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10531
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66
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15500
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67
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6368
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191
10565
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201
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8515
69
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8035
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13116
13131
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11847
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70
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9330
13435
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11841
10982
6274
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13440
13571
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10265
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13590
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8579
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6297
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10269
12307
8370
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14923
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11347
8064
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12263
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10051
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15527
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9310
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6325
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8069
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14885
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11578
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11692
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11705
11869
11977
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11990
11991
11994
11995
12168
12200
12238
12247
12271
6331
8262
10951
6332
8181
6333
8879
6334
14742
14741
6335
108
8831
8072
13582
6336
8073
8074
8075
6337
8504
8505
15287
8179
8953
8950
8936
10085
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10084
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8945
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8129
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Procedure Name
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Location
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Consent
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Date Time Start
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Date Time End
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VITALS PRIOR TO PROCEDURAL SEDATION
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Vital Signs & Other Observations
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OXYGEN DELIVERY DURING PROCEDURAL SEDATION
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Method Of Oxygen Delivery
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Flow Rate Delivered
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MEDICATION
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Administration Of Resuscitation Drugs
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SEDATION DOCUMENTATION
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Patient's Behaviour Immediately Prior To The Administration Of The Sedation Drugs
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Sedation Was Unsuccessful
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ADVERSE OUTCOME DOCUMENTATION
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Oxygen Desaturation <90%
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Clinically Apparent Pulmonary Aspiration
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Bradycardia
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Hypotension
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Excitatory Movements
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Unpleasant Recovery Reactions
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Permanent Complications
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Respiratory Depression
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Requiring Endotracheal Intubation After The Procedure
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Others
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SIGNATURES
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VITALS PRIOR TO PROCEDURAL SEDATION
OXYGEN DELIVERY DURING PROCEDURAL SEDATION
MEDICATION
SEDATION DOCUMENTATION
ADVERSE OUTCOME DOCUMENTATION
SIGNATURES
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