Dictate History & Physical
A complete history and physical must be recorded within 24 hours of admission.
IDENTIFY yourself clearly (first and last name), spell the patient’s first and last name, and give the patient medical record number.
The HISTORY should contain:
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Date History taken
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Patient’s chief complaint
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Present Illness
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Past History
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Social History
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Family History
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Review of Systems
The PHYSICAL EXAMINATION should contain:
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Date of Exam
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Pertinent findings by each Body System
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Provisional Diagnoses
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Recommendations
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