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Category Archives: EHR/EMR

The Comprehensive Adult Health History

16-Apr-17

Initial Information Data and Time of History The date is always important. Be sure to document the time you evaluate the patient, especially in urgent, emergent, or hospital setitngs. Identify Data These include age, gender, marital status, and occupation. The source of history or referral can be the patient, a family member or friend, an […]