A general observation indicating that the patient shows no immediate signs of illness or discomfort and appears to be in a healthy nutritional and developmental state.
Used as a general introductory statement in the physical examination portion of a medical note to describe the patient's overall apparent health status.
"General: Well-developed, well-nourished, and in no acute distress. Head: Normocephalic, atraumatic. Eyes: PERRLA. "
Initial assessment of the patient's overall appearance.
Common questions about using medical phrases in clinical documentation