Record Documentation History and Physical 1
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Get it written →hi/OneDrive/Desktop/AUDIT%20%20TOOLS%20H%20&%20P(1).pdf T Record Documentation History and Physical 1. What is patient’s current age? he is 51 years old 2 . What is chief complaint (CC)? 3 weeks of worsening dyspnea on light exertion 3. What is admitting diagnosis? 4. What are the pre-existing diagnoses? 5 . List patient’s current medications. 6. What are patient’s allergies? 7. List patient’s surgical history.
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