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dard formats for written documentation, which will be useful for you to learn. As you review these histories, you will encounter a number of technical terms for symptoms. Definitions of terms, together with ways to ask about symptoms, can be found in each of the regional examination chapters.

Is you acquire the techniques of the history taking and physical examination, ^member the important differences between subjective information and ob-ective information, as summarized in the table below. Knowing these differences helps you apply clinical reasoning and cluster patient information. These distinctions are equally important for organizing written and oral presentations concerning the patient.

Subjective Data

Objective Data

What the patient tells you

What you detect on the examination

The history, from chief complaint through Review of Systems

All physical examination findings

Example: Mrs. G is a 54-year-old hairdresser who reports pressure over her left chest "like an elephant sitting there," which goes into her left neck and arm.

Example: Mrs. G is an older white female, deconditioned, pleasant, and cooperative. BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.

H The Comprehensive Adult Health History_

Date and Time of History. The date is always important. You are strongly advised to routinely document the time you evaluate the patient, especially in urgent, emergent, or hospital settings.

Identifying Data. Includes age, gender, marital status, and occupation. The source of history or referral can be the patient, a family member or friend, an officer, a consultant, or the medical record. Patients requesting evaluations for schools, agencies, or insurance companies may have special priorities compared to patients seeking care on their own initiative. Designating the source of referral helps you to assess the type of information provided and any possible biases.

Reliability. Should be documented if relevant. For example, "The patient is vague when describing symptoms and unable to specify details." This judgment reflects the quality of the information provided by the patient and is usually made at the end of the interview.

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