PATIENT MEDICAl CHART Flashcards
1
Q
Reason the patient is seeking medical care
A
Chief complaint
2
Q
Medical history of patient’s first degree relatives
A
Family history
3
Q
Cigarette and alcohol use, occupation, sexual history, illicit drug use
A
Social history
4
Q
Vital signs
A
Physical examination
5
Q
Summary of patient complaints not included in HPI
A
Review of systems
6
Q
Narrative of the current medical problem
A
History of present illness
7
Q
Current and previous patient t problems unrelated to the present illness
A
Past medical history
8
Q
Admission date, patient name, age, gender, race
A
General patient information
