for the rectal examination.
Now you are ready to review an actual written record documenting a patient's history and physical findings, illustrated below using the example of "Mrs. N." The history and physical examination form the database for your subsequent assessment(s) of the patient and your plan(s) with the patient for management and next steps. Your written record organizes the information from the history and physical examination and should clearly communicate the patient's clinical issues to all members of the health care team. You will find that following a standardized format is often the most efficient and helpful way to transfer this information.
Your written record should also facilitate clinical reasoning and communicate essential information to the many health professionals involved in your patient's care. Chapter 18, Clinical Reasoning, Assessment, and Plan, will provide more comprehensive information for formulating the assessment and ïlan, and additional guidelines for documentation.
' you are a beginner, organizing the Present Illness may be especially chal-enging, but do not get discouraged. Considerable knowledge is needed to cluster related symptoms and physical signs. If you are unfamiliar with hyper-thyroidism, for example, it may not be apparent that muscular weakness, heat intolerance, excessive sweating, diarrhea, and weight loss, all represent a Present Illness. Until your knowledge and judgment grow, the patient's story and the seven key attributes of a symptom (see p.__) are helpful and necessary guides to what to include in this portion of the record.
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