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The form collects detailed patient history including allergies, medications, past medical history, surgical history, and social history.
It includes a structured ROS section that allows healthcare providers to mark symptoms as positive or negative across multiple body systems.
The form outlines specific physical examination components, ensuring thorough assessment of various systems such as cardiovascular, respiratory, gastrointestinal, and neurological.
There is a dedicated section for assessment and planning which helps in documenting the hospital status and medical decision-making level.
The form includes standardized codes for different levels of service (e.g., Level 1 to Level 3), facilitating accurate billing and coding for insurance purposes.
Both resident and attending physician signatures are required on the form to validate the documentation and ensure accountability.
