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Chapter 2

Sections of Health Records

TermDefinition
Chief of Complaint The Main reason for the patients visit
History of present illness The story of the patients problems
Review of systems Descriptions of individual body systems in order to discover any symptoms not directly related to the main problem
Past medical history Other significant past illnesses, like high blood pressure asthma, or diabetes
Past Surgical history Any of patients past surgery
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 that can impact health
Created by: krussell92
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