Chapter 15 - c/c HX of present illness HX Current health...

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Chapter 15: Documentation Uses for PCR’s o Medical o Administrative o Research o Legal Elements of Good Documentation Accuracy Legibility Timeliness Absence of alterations Professionalism Narrative Sections Subjective Narrative- any information elicited during your Patient’s HX.
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Unformatted text preview: c/c HX of present illness HX Current health status Objective Narrative- General impression Vital signs/EKG Physical exam Assessment/Management- field diagnosis & treatment....
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