Chapter 2 (Sections of a Health Record) Flashcards
1
Q
chief complaint
A
the main reason for the patient’s visit
2
Q
history of present illness
A
the story of the patient’s problem
3
Q
review of systems
A
description of individual body systems in order to discover any symptoms not directly related to the main problem
4
Q
past medical history
A
other significant past illnesses
5
Q
past surgical history
A
any of the patient’s past surgeries
6
Q
family history
A
any significant illnesses that run in the patient’s family
7
Q
social history
A
a record of habits that can impact health
