HIT 114 - Chapter 6: Patient Record Documentation …

Review the following patient record entry, and determine in which report itwould be documented. Skin No jaundice reveals pale, cool, and moist surface. Chest Respirations normal. Lungs Clear on inspection, percussions, and auscultation. Abdomen No tenderness, guarding, or rigidity. Extremities No significant findings Genitalia Normal Rectal Deferred a. chief complaint c. ….

Back to list Go To The Website

Popular Posts: