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hi my name is David Keegan Im an academic family doctor here at the University of Calgary were talking now about how to write or document your admission history and physical this also applies to major physical exams of any sort of type okay so first of all think about what the key purposes of doing this are we talked in other videos about the importance of tracking information for your own sake tracking information for the sake of other health care providers and to be a document of how things were so that in the future if theres any sort of medical legal or quality of care issues weve got it all documented and with those things in mind you need two elements you need clarity you need accuracy so the clarity will have impacts on how you set up your knows how to write it or frankly you know print it to make sure its actually readable you know too so that theres clear headings and all that kind of stuff and then the accuracy is making sure that youre documenting things properly so
