Make an appointment with your laboratory faculty if you are having any problems or if you have questions. Adult History Taken from your laboratory partner. History obtained from patient records and parent if possible. Physical findings all systems. Complete sentences are not required.
Short phrases are preferred.
Use the client's words whenever possible indicating their use by quotes. The history is subjective data and should be documented as reported even if thought not to be correct by the provider. It is often beneficial to repeat history to client to help verify its correctness. Begin with pertinent positives and then include pertinent negatives. The assessment is your conclusion after collecting all your subjective and objective data.