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 that are not directly related to the problem.
4
Q
Past medical history
A
Other significant past illnesses
5
Q
Past surgical history
A
Patient’s past surgeries
6
Q
Family history
A
Any significant illness that runs in the patient’s family
7
Q
Social history
A
A record of habits like smoking, drinking, drug use that can affect health
