1. Lesson Five Problem List, Vital Signs, Immunizations, Progress Note
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2. PROBLEM LIST, VITAL SIGNS, IMMUNIZATIONS, PROGRESS NOTE
»» Complete a list of patient problems in one accessible area
»» Free text of encoded problem lists
»» Include onset and resolution date

3. PROBLEM LIST, VITAL SIGNS, IMMUNIZATIONS, PROGRESS NOTE
»» Cardinal signs
»» Temperature (T)
»» Pulse Rate (P)
»» Respirations (R)
»» Blood pressure (BP)
Anthropometric Measurements
»» Physical measurement
»» Weight measured at every visit
»» Height measured at the first visit and annually
»» Head circumference measured for pediatric patients or patients with a relevant illness
»» First visit measurements are baseline data
»» Reference points for other visits

4. PROBLEM LIST, VITAL SIGNS, IMMUNIZATIONS, PROGRESS NOTE
»» Name of immunization
»» Name of person administering immunization
»» Date given
»» Location of injection
»» Manufacturer
»» Type
»» Expiration date
»» Lot number
Before any medications or immunizations are administered the medical assistant must have a documented order from the physician.

5. PROBLEM LIST, VITAL SIGNS, IMMUNIZATIONS, PROGRESS NOTE
»» S: Subjective
»» How the patient describes symptoms.
»» O: Objective
»» Completed by physician, based on physician observations and testing
»» A: Assessment
»» Completed by physician, based on information provided in Subjective and Objective fields
»» P: Plan
»» Completed by physician, strategies for addressing patient symptoms
»» E: Evaluation
»» Completed by physician, the effectiveness of the Plan
Digital Signature
»» Notation of when and by whom a Progress Note is signed, shown below the signature line.
»» When a note is signed electronically, the physician represents that everything within the note is correct.