Comprehensive Health History and Physical Exam assessment Summary
Comprehensive Health History and Physical Exam assessment Summary
Order Description
1. Subjective data
Provide detailed demographic data of an adult patient who has multiple medical history
2. health History
Detailed information, past medical history
past surgical history
past social history
family History
Current medication( frequency, dosage, Reason)
Immunization History
Health maintenance
patient problem list by system
3. Objective data and review system . provide detailed on all 22 system example , General, skin, hair, nails, eyes, ears, mouth , nasal/ sinuses plus all
Summary
write detailed summary/ strengths/ deficits/ health related diagnosis and concerns based on SBAR
Careplan