Charting Question??

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Upon doing my physical assessment I noted that my pt has an amputated finger. Pt lost it as a child, it is not a part of their current hospitalization, but must be documented. Seems easy enough to chart, but for some reason I just can't seem to phrase it without it sounding like it is a current amputation. Can anyone help me?

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Can you put it under surgical Hx or Health Hx " amputated finger during childhood

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Can you put it under surgical Hx

Or health Hx

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I can in the wonderful world of computer charting, but for school purposes they want this included in our nurses notes. Ugh. After writing it several different ways, I came up with: * No Rt middle finger. Pt states "amputated when I was a child." Do you think this is sufficient enough?

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Yes that's good but say amputated R middle finger instead it sound more "nursey" lol

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Okay :) Thank you for the tip!! It is very much appreciated!

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No problem at all

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