CLINIC NOTE CC: Patient Presents for Routine Examination

question 11

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.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________

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Definitions:

Null Hypothesis

It is a hypothesis that assumes no significant difference or effect; it is the statement tested in statistical hypothesis testing to determine the likelihood of the observed data.

Statistically Significant

A determination that the observed difference or relationship in a statistic is not likely due to chance alone, according to a pre-specified threshold of significance.

Confidence Interval

A range of values derived from sample statistics that is likely to contain the true value of an unknown population parameter.

Null Hypothesis

In statistics, a hypothesis that proposes no significant difference or effect; the hypothesis that a researcher tries to disprove.