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: a record of a past medical problems and treatments that a person has had.

History of Present Illness Chief complaint (CC) History of present illness (HPI) Review of systems (ROS) Past, family and/or social history (PFSH)

Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication.

It consists of using directed, focused interview questions and open-ended questions to obtain symptoms and perceptions from the patient about their illnesses, functioning, and life processes. While obtaining a health history, the nurse is also simultaneously performing a general survey.

The term of Medical Records is vast and vaguely defined. It encompasses, but is not necessarily limited to, the admission sheet, history sheet, progress of a patient as well as the charts of his or her vital parameters, intake?output data, medications given, referrals, and discharge summary.

Medical Record Keeping Definition These records may include information on illnesses, medical conditions, lab results, immunizations, screenings, biographical data, and documentation of services. In the present day, most medical records are digitally stored, allowing them to be easily accessed in electronic databases.

Obtain a detailed history of the pertinent and. necessary information regarding the patient. ... Provide an accurate description of the. relevant symptoms and events in the. ... Interpret the information obtained in terms of. ... Present the patient history and generate a. ... Summarize the history emphasizing the mos.