Healthy History Documentation Help

Healthy History Documentation Instructions

Complete your documentation using the documentation template ( template below)

Included the Information in different attachment and template – Please use only the information can be equal the document

Name: Danny Rivera

Section:

Week 5

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

  • Chief Complaint (CC):
  • History of Present Illness (HPI):
  • Medications:
  • Allergies:
  • Past Medical History (PMH):
  • Past Surgical History (PSH):
  • Sexual/Reproductive History:
  • Personal/Social History:
  • Immunization History:
  • Health Maintenance:

Healthy History Documentation Help Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History).Remember that the information you include in this Healthy History Documentation Help section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

Healthy History Documentation Help

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate Healthy History Documentation Help HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

Instructions

Complete your documentation using the documentation template

Included the Information in different attachment and template

© 2021 Walden University Page 1 of 1

Healthy History Documentation Help APA Paper Formatting Basics

  1. All text should be double-spaced.
  2. Use one-inch margins on all sides.
  3. All paragraphs in the body are indented.
  4. Make sure that the title is centered on the page with your name and school/institution underneath.
  5. Use 12-point font throughout.
  6. All pages should be numbered in the upper right hand corner

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