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Types of Records

Chapter 2

TermDefinition
Sections of Health Records
Chief Complaint The main reason for the patient's visit
History of Present Illness The story of the patient's problem
Review of Systems Description of their body systems in order to discover any symptoms not directly related to main problem
Past Medical History Other significant past illnesses, like high blood pressure, asthma, or diabetes
Past Surgical History Any of the patient's past surgeries
Family History Any significant illnesses that run in the patients family
Social History A record of habits like smoking, drinking, drug abuse, and sexual practices.
Created by: JenHope
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