SOLUTIONS TO EXERCISES, LESSON 1
The nature of the case and treatment given. (para 1-9a)
To identify the person making the entry. (para 1-10c)
The physical examination must be current (must have been completed within
the 24 hours period preceding the examination).
The physical examination must be related to the illness for which the patient is
Findings must be recorded in specific terms. (para 1-12b)
Patient's name, rank, grade or status, family member prefix, sponsor's SSN, and
register number (para 1-11a)
Reason for hospitalization.
All procedures performed and treatment given.
Condition of patient at time of transfer or discharge.
All relevant diagnosis. (para 1-17a)
To provide a written record of the treatment and care of each patient when he is
To demonstrate compliance with Army regulations and JCAHO standards.
To provide a measure of the quality of patient care.
To provide legal documentation of patient care. (para 1-18)
Complete the ITRCS worksheet.
Dictate the Narrative Summary.
Make final progress notes. (para 1-20a(1))