Health History Documentation Example

Shortness of breath respiratory.

Health history documentation example. I got lightheadedness and felt too weak to walk source and setting. These components of the comprehensive adult health history are more fully described in the next few pages. No chest pain cardiovascular.

Besides it may be an extreme disservice to the ailing person. Cb 7110 chapel hill nc 27599 phone. It generally begins with the basic identity details of the person.

Carol carden carol carden med unc edu division of general medicine 5034 old clinic bldg. Or belly pain gastrointestinal. Comprehensive adult history and physical sample summative h p by m2 student chief complaint.

A comprehensive document providing the patients past medical history personal and contact details health information habits living standards and family medical history with their consent to the terms and conditions. These sample adult and pediatric health histories fol low standard formats for written documentation which you will need to learn. Then it goes on with sections on the medications taken by the person history of any critical health condition any health issue he is suffering from currently family history ethnicity background the vaccinations taken infection risks etc.

This is the 3rdcpmc admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal toothache like chest pain of 12 hours. Patient reported in an in patient setting on day 2 of his hospitalization. So you need to include it with your doctor.

For example a problem focused history requires documentation of the chief complaint cc and a brief history of present illness hpi while a detailed history requires the documentation of a cc an extended hpi plus an extended review of systems ros and pertinent past family and or social history pfsh. That way you can share the information with any doctors you see. Example of a complete history and physical write up.