KevinMD August 20, 2024
It had been a busy day. He was the last patient of the day.
In the oncology outpatient department, we have forms for documenting a patient’s medical history. The form has specific sections that need to be filled out in a set order. First, we start with the presenting complaint, followed by the history of presenting illness. Next, we document the patient’s past medical and surgical history, followed by sections for menstrual history, addictions, current medications, and their frequencies, and finally, personal details such as marital status, number of children, and occupation.
I’m not too fond of that form and never follow it in order. I find it ridiculous. I mostly start with the introduction, personal history, etc. Sometimes, I...
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