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1NOTE BOOK FOR HISTORY TAKING AND PATIENT`S RECORDDepartment of Medical Education Khyber Medical College Peshawar2History S. No___,Unit:___,Date:___Biodata Patient name:Age:Marital status: Presenting
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01
Label the front cover of the notebook with 'History Taking and Patient Record'
02
Divide the notebook into sections for different patients or cases
03
Begin each entry with the date and patient's name
04
Document the patient's medical history, chief complaint, vital signs, physical examination findings, diagnoses, and treatment plans
05
Include any relevant lab results, imaging reports, or referrals
06
Make sure to write legibly and use clear, concise language

Who needs note-book-for-history-taking-and-patient-record?

01
Medical professionals such as doctors, nurses, and physician assistants
02
Students studying medicine or healthcare
03
Healthcare facilities and clinics for maintaining accurate patient records
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The note-book-for-history-taking-and-patient-record is a dedicated document used by healthcare professionals to systematically record patient medical histories, observations, and ongoing treatment information.
Healthcare providers, including doctors, nurses, and other medical practitioners, are required to maintain and file the note-book-for-history-taking-and-patient-record for their patients.
To fill out the note-book-for-history-taking-and-patient-record, healthcare providers should enter the patient's personal information, medical history, symptoms, diagnosis, treatment plan, and any follow-up notes in a clear and organized manner.
The purpose of the note-book-for-history-taking-and-patient-record is to ensure accurate documentation of patient care, facilitate continuity of care, and provide legal protection for both the patient and healthcare provider.
The note-book-for-history-taking-and-patient-record must include patient identification details, medical history, reason for visit, examination findings, diagnosis, treatment plan, medications prescribed, and follow-up instructions.
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