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Writing the History and Physical and Progress Notes — Set 2

30 questions from Prof. Finck's “Writing the History and Physical and Progress Notes” lecture · Interpersonal communication · History and physical format · Chief complaint, history of present illness, past medical, social and family history · Documenting the physical examination · Differential diagnoses, assessment and plan · The progress note · Documentation errors
30 questions

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Discuss interpersonal communication skills that result in effective information exchange with patients, families and the health care team.Discuss the importance of consistency in medical documentation and the implications of errors.Describe the use and format of the history and physical and the progress note.Discuss the importance of documenting differential diagnoses, assessment, testing, disposition, referrals, follow-up, education and management.

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