Template:Medical Record/Example: Difference between revisions
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(Created page with "<pre style="white-space:pre-wrap"> {{Medical Record LCARS |SERIAL NUMBER= EZ - 123 - 456 |BIRTHYEAR= 2363 |BIRTHMONTH= 01 |BIRTHDATE= 01 |SEX= Female |SPECIES= Human |HEIG...") |
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|PAST SURGICAL HISTORY= | |PAST SURGICAL HISTORY= | ||
*'''SD 238911.12:''' Knee surgery | *'''SD 238911.12:''' Knee surgery | ||
**'''Surgeon:''' | **'''Surgeon:''' [[Niccolò del Vedova]], MD | ||
**'''OR Site:''' {{USS|Mercury}} | **'''OR Site:''' {{USS|Mercury}} | ||
**'''Op Note:''' Link to sim | **'''Op Note:''' Link to sim | ||
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|RECREATIONAL DRUG USE= None | |RECREATIONAL DRUG USE= None | ||
|OTHER SUBSTANCE USE= None | |OTHER SUBSTANCE USE= None | ||
| | |PARENT 1= Mother | ||
| | |PARENT 1 MEDICAL HISTORY= None | ||
|PARENT 2= Father | |||
|PARENT 2 MEDICAL HISTORY= Cardiovascular disease | |||
|SIBLING MEDICAL HISTORY= None | |SIBLING MEDICAL HISTORY= None | ||
|MARITAL STATUS & SPOUSE= Married to Elliot Smith | |MARITAL STATUS & SPOUSE= Married to Elliot Smith | ||
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|EXERCISE= Running, 3 times a week | |EXERCISE= Running, 3 times a week | ||
|PHYSICIANS NOTE= | |PHYSICIANS NOTE= | ||
*'''SD 239004.23 - Medical Officer:''' {{ | *'''SD 239004.23 - Medical Officer:''' [[Niccolò del Vedova]], MD, {{USS|Mercury}} | ||
*'''Medical Assessment:''' Ensign Smith is a 27-year-old human female who presents with abdominal pain and generalized weakness. She states the symptoms began last Thursday after eating a bowl of Commander McLaughin's "Sweet Chili Surprise" at the ship's annual cook off contest. I've started her on an intense bowel cleansing therapy which should be followed to completion through | *'''Medical Assessment:''' Ensign Smith is a 27-year-old human female who presents with abdominal pain and generalized weakness. She states the symptoms began last Thursday after eating a bowl of Commander McLaughin's "Sweet Chili Surprise" at the ship's annual cook off contest. I've started her on an intense bowel cleansing therapy which should be followed to completion through next week. | ||
<hr> | <hr> | ||
*'''SD 239004.27 - Medical Officer:''' {{ | *'''SD 239004.27 - Medical Officer:''' [[Niccolò del Vedova]], MD, {{USS|Mercury}} | ||
*'''Addendum:''' Ensign Smith returned to sickbay today stating she felt much better, insisting that her cleansing therapy was no longer necessary. I told her nonsense and sent her on her way. | *'''Addendum:''' Ensign Smith returned to sickbay today stating she felt much better, insisting that her cleansing therapy was no longer necessary. I told her nonsense and sent her on her way. | ||
|COUNSELORS NOTE= | |COUNSELORS NOTE= | ||
*'''SD 239004.28 - Counselor:''' Lt. Rachel Simmons | *'''SD 239004.28 - Counselor:''' Lt. Rachel Simmons, {{USS|Mercury}} | ||
*'''Counseling Assessment:''' Ensign Smith came to my office today in tears. It seems her recent medical illness due to her unfortunate encounter with McLaughlin's chili has left her feeling vulnerable and alone. I have advised her to continue daily therapy sessions with me until further notice. | *'''Counseling Assessment:''' Ensign Smith came to my office today in tears. It seems her recent medical illness due to her unfortunate encounter with McLaughlin's chili has left her feeling vulnerable and alone. I have advised her to continue daily therapy sessions with me until further notice. | ||
}} | }} | ||
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|PAST SURGICAL HISTORY= | |PAST SURGICAL HISTORY= | ||
*'''SD 238911.12:''' Knee surgery | *'''SD 238911.12:''' Knee surgery | ||
**'''Surgeon:''' | **'''Surgeon:''' [[Niccolò del Vedova]], MD | ||
**'''OR Site:''' {{USS|Mercury}} | **'''OR Site:''' {{USS|Mercury}} | ||
**'''Op Note:''' Link to sim | **'''Op Note:''' Link to sim | ||
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|RECREATIONAL DRUG USE= None | |RECREATIONAL DRUG USE= None | ||
|OTHER SUBSTANCE USE= None | |OTHER SUBSTANCE USE= None | ||
| | |PARENT 1= Mother | ||
| | |PARENT 1 MEDICAL HISTORY= None | ||
|PARENT 2= Father | |||
|PARENT 2 MEDICAL HISTORY= Cardiovascular disease | |||
|SIBLING MEDICAL HISTORY= None | |SIBLING MEDICAL HISTORY= None | ||
|MARITAL STATUS & SPOUSE= Married to Elliot Smith | |MARITAL STATUS & SPOUSE= Married to Elliot Smith | ||
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|EXERCISE= Running, 3 times a week | |EXERCISE= Running, 3 times a week | ||
|PHYSICIANS NOTE= | |PHYSICIANS NOTE= | ||
*'''SD 239004.23 - Medical Officer:''' {{ | *'''SD 239004.23 - Medical Officer:''' [[Niccolò del Vedova]], MD, {{USS|Mercury}} | ||
*'''Medical Assessment:''' Ensign Smith is a 27-year-old human female who presents with abdominal pain and generalized weakness. She states the symptoms began last Thursday after eating a bowl of Commander McLaughin's "Sweet Chili Surprise" at the ship's annual cook off contest. I've started her on an intense bowel cleansing therapy which should be followed to completion through | *'''Medical Assessment:''' Ensign Smith is a 27-year-old human female who presents with abdominal pain and generalized weakness. She states the symptoms began last Thursday after eating a bowl of Commander McLaughin's "Sweet Chili Surprise" at the ship's annual cook off contest. I've started her on an intense bowel cleansing therapy which should be followed to completion through next week. | ||
<hr> | <hr> | ||
*'''SD 239004.27 - Medical Officer:''' {{ | *'''SD 239004.27 - Medical Officer:''' [[Niccolò del Vedova]], MD, {{USS|Mercury}} | ||
*'''Addendum:''' Ensign Smith returned to sickbay today stating she felt much better, insisting that her cleansing therapy was no longer necessary. I told her nonsense and sent her on her way. | *'''Addendum:''' Ensign Smith returned to sickbay today stating she felt much better, insisting that her cleansing therapy was no longer necessary. I told her nonsense and sent her on her way. | ||
|COUNSELORS NOTE= | |COUNSELORS NOTE= | ||
*'''SD 239004.28 - Counselor:''' Lt. Rachel Simmons | *'''SD 239004.28 - Counselor:''' Lt. Rachel Simmons, {{USS|Mercury}} | ||
*'''Counseling Assessment:''' Ensign Smith came to my office today in tears. It seems her recent medical illness due to her unfortunate encounter with McLaughlin's chili has left her feeling vulnerable and alone. I have advised her to continue daily therapy sessions with me until further notice. | *'''Counseling Assessment:''' Ensign Smith came to my office today in tears. It seems her recent medical illness due to her unfortunate encounter with McLaughlin's chili has left her feeling vulnerable and alone. I have advised her to continue daily therapy sessions with me until further notice. | ||
}} | }} |
Latest revision as of 16:08, 30 September 2022
{{Medical Record LCARS |SERIAL NUMBER= EZ - 123 - 456 |BIRTHYEAR= 2363 |BIRTHMONTH= 01 |BIRTHDATE= 01 |SEX= Female |SPECIES= [[Human]] |HEIGHT= 161 cm (5'3") |WEIGHT= 56 kilos (123 lbs) |BLOOD TYPE= B+ |T/E RATING= T0 |CHRONIC ILLNESSES= None |MEDICATIONS= None |ALLERGIES & REACTIONS= Strawberries (hives) |SEXUAL/REPRODUCTIVE HISTORY= Longterm male partner |PAST HOSPITALIZATIONS/SERIOUS ILLNESS= *'''2388:''' Tarkalean flu |PAST SURGICAL HISTORY= *'''SD 238911.12:''' Knee surgery **'''Surgeon:''' [[Niccolò del Vedova]], MD **'''OR Site:''' {{USS|Mercury}} **'''Op Note:''' Link to sim |PSYCHIATRIC HISTORY= None |ALCOHOL USE= 2 glasses of wine per week |RECREATIONAL DRUG USE= None |OTHER SUBSTANCE USE= None |PARENT 1= Mother |PARENT 1 MEDICAL HISTORY= None |PARENT 2= Father |PARENT 2 MEDICAL HISTORY= Cardiovascular disease |SIBLING MEDICAL HISTORY= None |MARITAL STATUS & SPOUSE= Married to Elliot Smith |CHILDREN= 1 son |OCCUPATION= Helmsman |DIET= Vegetarian |EXERCISE= Running, 3 times a week |PHYSICIANS NOTE= *'''SD 239004.23 - Medical Officer:''' [[Niccolò del Vedova]], MD, {{USS|Mercury}} *'''Medical Assessment:''' Ensign Smith is a 27-year-old human female who presents with abdominal pain and generalized weakness. She states the symptoms began last Thursday after eating a bowl of Commander McLaughin's "Sweet Chili Surprise" at the ship's annual cook off contest. I've started her on an intense bowel cleansing therapy which should be followed to completion through next week. <hr> *'''SD 239004.27 - Medical Officer:''' [[Niccolò del Vedova]], MD, {{USS|Mercury}} *'''Addendum:''' Ensign Smith returned to sickbay today stating she felt much better, insisting that her cleansing therapy was no longer necessary. I told her nonsense and sent her on her way. |COUNSELORS NOTE= *'''SD 239004.28 - Counselor:''' Lt. Rachel Simmons, {{USS|Mercury}} *'''Counseling Assessment:''' Ensign Smith came to my office today in tears. It seems her recent medical illness due to her unfortunate encounter with McLaughlin's chili has left her feeling vulnerable and alone. I have advised her to continue daily therapy sessions with me until further notice. }}
Medical Record
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MEDICAL RECORD | ||
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PAST MEDICAL HISTORY
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PAST HOSPITALIZATIONS/SERIOUS ILLNESS
PAST SURGICAL HISTORY
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PSYCHIATRIC HISTORYNone SUBSTANCE USE HISTORY
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FAMILY MEDICAL HISTORY
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SOCIAL HISTORY
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PHYSICIANS' NOTES
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COUNSELORS' NOTES
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