Document each area addressed. If history has been previously documented, a notation that it was reviewed is adequate. PMH includes prior illnesses, injuries, hospitalizations, current medications, allergies, and immunization status. SH includes occupation, marital status, living situation, level of education, sexual history, and use of alcohol, tobacco, and drugs.
Normal notation is sufficient.
Describe abnormals in detail. Tally points as follows. Tally points as follows. Highest risk from any of the 3 categories determines overall risk. Each complexity level requires at least 2 of the 3 components listed.