Template:Medical Record/Example: Difference between revisions

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{{{{Medical Record LCARS
{{Medical Record LCARS
|SERIAL NUMBER= HC-018-080
|SERIAL NUMBER= EZ - 123 - 456
|BIRTHYEAR= 2371
|BIRTHYEAR= 2363
|BIRTHMONTH= 09
|BIRTHMONTH= 01
|BIRTHDATE= 02
|BIRTHDATE= 01
|SEX= Female
|SEX= Female
|SPECIES= [[Human]] / [[Centauran]]
|SPECIES= [[Human]]
|HEIGHT= 1.67 m
|HEIGHT= 161 cm (5'3")
|WEIGHT= 54 kg
|WEIGHT= 56 kilos (123 lbs)
|BLOOD TYPE= AB positive
|BLOOD TYPE= B+
|T/E RATING= T0/E0
|T/E RATING= T0
|CHRONIC ILLNESSES= None
|CHRONIC ILLNESSES= None
|MEDICATIONS= Receiving regular contraceptive injections
|MEDICATIONS= None
|ALLERGIES & REACTIONS= Possible intolerance for certain grains (i.e. hops)
|ALLERGIES & REACTIONS= Strawberries (hives)
|SEXUAL/REPRODUCTIVE HISTORY= Active, no pregnancies
|SEXUAL/REPRODUCTIVE HISTORY= Longterm male partner
|PAST HOSPITALIZATIONS/SERIOUS ILLNESS=
|PAST HOSPITALIZATIONS/SERIOUS ILLNESS=
*None
*'''2388:''' Tarkalean flu
|PAST SURGICAL HISTORY=
|PAST SURGICAL HISTORY=
*'''2371''': At birth, left leg amputation (due to complications)
*'''SD 238911.12:''' Knee surgery
*'''2372''': At 8 months, bioelectrical implantation for neurologically-controlled prosthesis
**'''Surgeon:''' [[Niccolò del Vedova]], MD
*'''2390''': At 19 years, wisdom teeth removal
**'''OR Site:''' {{USS|Mercury}}
|PSYCHIATRIC HISTORY=  
**'''Op Note:''' Link to sim
*None, regular counselling
|PSYCHIATRIC HISTORY= None
|ALCOHOL USE= Occasional
|ALCOHOL USE= 2 glasses of wine per week
|RECREATIONAL DRUG USE= None
|RECREATIONAL DRUG USE= None
|OTHER SUBSTANCE USE= Mild caffeine intake
|OTHER SUBSTANCE USE= None
|PARENT 1 = Birth Mother
|PARENT 1= Mother
|PARENT 1 MEDICAL HISTORY= Melissa Hopper (Human),  civilian file not available without requisition
|PARENT 1 MEDICAL HISTORY= None
|PARENT 2 = Biological Mother
|PARENT 2= Father
|PARENT 2 MEDICAL HISTORY= Ansyra Hopper (Centauran), civilian file not available without requisition
|PARENT 2 MEDICAL HISTORY= Cardiovascular disease
|SIBLING MEDICAL HISTORY= Kerilyn Hopper (Human/Centauran), civilian file not available without requisition
|SIBLING MEDICAL HISTORY= None
|MARITAL STATUS & SPOUSE= Single
|MARITAL STATUS & SPOUSE= Married to Elliot Smith
|CHILDREN= None
|CHILDREN= 1 son
|OCCUPATION= Chief Science Officer, [[Amity Outpost]]
|OCCUPATION= Helmsman
|DIET= Vegetarian
|DIET= Vegetarian
|EXERCISE= Typical aerobics, cardiovascular health optimal
|EXERCISE= Running, 3 times a week
|PHYSICIANS NOTE=
|PHYSICIANS NOTE=
*'''239708.11 - Dr. Duran Larx''' (CMO, [[USS Wall Street]]): Ensign Hopper's health is excellent; Routine check-ups recommended.
*'''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=
|COUNSELORS NOTE=
* None on file
*'''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.
}}
}}
</pre>
</pre>


{{Medical Record LCARS
{{Medical Record LCARS
|SERIAL NUMBER= HC-018-080
|SERIAL NUMBER= EZ - 123 - 456
|BIRTHYEAR= 2371
|BIRTHYEAR= 2363
|BIRTHMONTH= 09
|BIRTHMONTH= 01
|BIRTHDATE= 02
|BIRTHDATE= 01
|SEX= Female
|SEX= Female
|SPECIES= [[Human]] / [[Centauran]]
|SPECIES= [[Human]]
|HEIGHT= 1.67 m
|HEIGHT= 161 cm (5'3")
|WEIGHT= 54 kg
|WEIGHT= 56 kilos (123 lbs)
|BLOOD TYPE= AB positive
|BLOOD TYPE= B+
|T/E RATING= T0/E0
|T/E RATING= T0
|CHRONIC ILLNESSES= None
|CHRONIC ILLNESSES= None
|MEDICATIONS= Receiving regular contraceptive injections
|MEDICATIONS= None
|ALLERGIES & REACTIONS= Possible intolerance for certain grains (i.e. hops)
|ALLERGIES & REACTIONS= Strawberries (hives)
|SEXUAL/REPRODUCTIVE HISTORY= Active, no pregnancies
|SEXUAL/REPRODUCTIVE HISTORY= Longterm male partner
|PAST HOSPITALIZATIONS/SERIOUS ILLNESS=
|PAST HOSPITALIZATIONS/SERIOUS ILLNESS=
*None
*'''2388:''' Tarkalean flu
|PAST SURGICAL HISTORY=
|PAST SURGICAL HISTORY=
*'''2371''': At birth, left leg amputation (due to complications)
*'''SD 238911.12:''' Knee surgery
*'''2372''': At 8 months, bioelectrical implantation for neurologically-controlled prosthesis
**'''Surgeon:''' [[Niccolò del Vedova]], MD
*'''2390''': At 19 years, wisdom teeth removal
**'''OR Site:''' {{USS|Mercury}}
|PSYCHIATRIC HISTORY=  
**'''Op Note:''' Link to sim
*None, regular counselling
|PSYCHIATRIC HISTORY= None
|ALCOHOL USE= Occasional
|ALCOHOL USE= 2 glasses of wine per week
|RECREATIONAL DRUG USE= None
|RECREATIONAL DRUG USE= None
|OTHER SUBSTANCE USE= Mild caffeine intake
|OTHER SUBSTANCE USE= None
|PARENT 1 = Birth Mother
|PARENT 1= Mother
|PARENT 1 MEDICAL HISTORY= Melissa Hopper (Human),  civilian file not available without requisition
|PARENT 1 MEDICAL HISTORY= None
|PARENT 2 = Biological Mother
|PARENT 2= Father
|PARENT 2 MEDICAL HISTORY= Ansyra Hopper (Centauran), civilian file not available without requisition
|PARENT 2 MEDICAL HISTORY= Cardiovascular disease
|SIBLING MEDICAL HISTORY= Kerilyn Hopper (Human/Centauran), civilian file not available without requisition
|SIBLING MEDICAL HISTORY= None
|MARITAL STATUS & SPOUSE= Single
|MARITAL STATUS & SPOUSE= Married to Elliot Smith
|CHILDREN= None
|CHILDREN= 1 son
|OCCUPATION= Chief Science Officer, [[Amity Outpost]]
|OCCUPATION= Helmsman
|DIET= Vegetarian
|DIET= Vegetarian
|EXERCISE= Typical aerobics, cardiovascular health optimal
|EXERCISE= Running, 3 times a week
|PHYSICIANS NOTE=
|PHYSICIANS NOTE=
*'''239708.11 - Dr. Duran Larx''' (CMO, [[USS Wall Street]]): Ensign Hopper's health is excellent; Routine check-ups recommended.
*'''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=
|COUNSELORS NOTE=
* None on file
*'''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.
}}
}}

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.
}}
Starfleet Medical.png

Medical Record

MEDICAL RECORD
  • Height: 161 cm (5'3")
  • Weight: 56 kilos (123 lbs)
  • Blood Type: B+
  • T/E Rating: T0

PAST MEDICAL HISTORY

  • Chronic Illnesses: None
  • Medications: None
  • Allergies and Reactions: Strawberries (hives)
  • Sexual/Reproductive History: Longterm male partner

PAST HOSPITALIZATIONS/SERIOUS ILLNESS

  • 2388: Tarkalean flu

PAST SURGICAL HISTORY

PSYCHIATRIC HISTORY

None

SUBSTANCE USE HISTORY

  • Alcohol: 2 glasses of wine per week
  • Recreation Drugs: None
  • Other: None

FAMILY MEDICAL HISTORY

  • Parent 1 (Mother): None
  • Parent 2 (Father): Cardiovascular disease
  • Siblings: None

SOCIAL HISTORY

  • Marital status: Married to Elliot Smith
  • Children: 1 son
  • Occupation/Assignment: Helmsman
  • Diet: Vegetarian
  • Exercise: Running, 3 times a week

PHYSICIANS' NOTES

  • 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.
  • 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' NOTES

  • 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.


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