Ch 3 Medical History & Patient Assessment

The difference between a sign & symptom is

Who can see or perceive the event

The ____ is documented in the patient’s medical records at each visit

Chief complaint

Where should patient interviews be conducted?

In a private room with the door closed

____ are objective information that can be observed or perceived by someone other than the patient

Sign

____ are indications of disease or changes in the body as sensed by the patient

Symptoms

Basic identification data is called

Demographic information

Items to include in asking about the CC during the patient interview are location, severity &

Chronology

The section that includes allergies, immunizations, childhood diseases, current & past medications, previous surgeries, illnesses and hospitalizations is called

Past history

Who is allowed access to the medical records?

Those directly involved with the patients care