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What are 6 common components of a social HX?

Family History, social history, allergies, past medical history, history of present illness, chief complaint, review of systems, meds, past surgical history. Besides Tobacco/alcohol/drugs, what other main questions are given during a social history?

What are the six components of medical history?

Basics of history taking Chief concern (CC) History of present illness (HPI) Past medical history (PMH) including preexisting illnesses, medication history, and allergies. Family history (FH) Social history (SH) Review of systems (ROS)

What are the four 4 major purposes of the medical record?

Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

What are the 4 components of medical history?

A medical record is a systematic documentation of a patient's medical history and care. It usually contains the patient's health information (PHI) which includes identification information, health history, medical examination findings and billing information.

What are the four components of a medical note?

Record of the patient's care that includes vital signs, particularly temperature (T), Pulse (P), Respiration (R), and blood pressure (BP). The procedures, and patient's responses to such care.

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What are the components of medical history?

A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.

What are the components to a medical history quizlet?

Terms in this set (18) Source & Reliability. Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) Social History (SH) Family History (FH) Review of Systems (ROS)

What are the 4 components of a patient's medical history?

A medical record is a systematic documentation of a patient's medical history and care. It usually contains the patient's health information (PHI) which includes identification information, health history, medical examination findings and billing information.

How can I get my medical history?

You may be able to request your record through your provider's patient portal. You may have to fill out a form \u2014 called a health or medical record release form, or request for access\u2014send an email, or mail or fax a letter to your provider.

What are the 12 main components of the medical record?

What Are The 10 Components Of A Medical Record? Identification Information. One of the first important components you can find in medical records is identification information. ... Medical History. ... Medication Information. ... Family History. ... Treatment History. ... Medical Directives. ... Lab results. ... Consent Forms.

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