Âm thanh chia sẻ

The following guidelines apply to the patient history component. A medically appropriate history should be documented Elements of the history of present illness do not have to be counted. The chief complaint may be documented by the patient or staff and reviewed by the physician. A review of multiple body systems is no longer required. Only the systems that are pertinent to the patient or that are medically relevant should be reviewed. For the past, family and social histories, only relevant