CLINIC NOTE CC: Patient Presents for Routine Examination

question 48

Short Answer

CLINIC NOTE

CC: Patient presents for routine examination

SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination.

OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.
ASSESSMENT:
1. Normal BP.
2. Normal pelvic exam.
Normal pelvic exam.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________

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Definitions:

Departmentalization

The process of dividing an organization into different departments or units, each specializing in a specific area of operation.

Organizational Structure

The system used to define a hierarchy within an organization, determining how roles, responsibilities, and authority are organized and how information flows between the levels of management.

Functional Structure

A type of organizational structure where the company is divided into departments or teams based on specialized functions, such as marketing, finance, or production.

Team-Based Structure

A team-based structure in an organization is a framework that emphasizes teamwork, with employees grouped into project teams or work-groups that operate semi-autonomously to accomplish specific tasks.