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Chapter 2 Health Care Records

AB
Aassessment
A & Walive and well
CCchief complaint
c/ocomplains of
Dxdiagnosis
FHfamily history
HEENThead, eyes, ears, nose, and throat
H&Phistory and physical
HPI, PIhistory of present illness, present illness
Hxhistory
IMPimpression
L&Wliving and well
NADno acute distress
NKA, NKDAno known allergies,l no known drug allergies
Oobjective information
OHoccupational histroy
Pplan
PE, Pxphysical exam
PERRLApupils equal, round, and reactive to light accommodation
PH, PMHpast history, past medical history
R/Orule out
ROS, SRreview of systems, systems review
Ssubjective information
SHsocial history
Sxsymptom
UCHDusual childhood diseases
WNLwithin normal limits



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