36555041
Description
Mind Map by katia lizaola , updated more than 1 year ago
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Created by katia lizaola
about 3 years ago
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MEDICAL RECORD
- Patients demographics
- are the personal data of
the patient
- are the personal data of
the patient
- Chief complaint
- main reason why the
patient asks for help
- main reason why the
patient asks for help
- History of presented illness
- documented in chronological
order
- documented in chronological
order
- Past medical history
- current medical conditons
- current medical conditons
- Family history
- hereditary
diseases
- hereditary
diseases
- physical examination
- thorough check from head to toe
- thorough check from head to toe
- Review of systems
- subjective patient symptoms
- subjective patient symptoms
- medication history
- prescription and alternative
medicines
- prescription and alternative
medicines
- Allergies
- Allergic reactions
- Allergic reactions
- social history
- patients lifestyle
- patients lifestyle
- Laboratory test result
- helps to have a better diagnosis
- helps to have a better diagnosis
- diagnostic test results
- clinical notes
- daily progress notes
- daily progress notes
- Treatment notes
- medications orders and documentacion
- medications orders and documentacion
Media attachments
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