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family history (FH) "noncontributory" Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase such as "no family h/o of heart or lung problems" may be used to specifically indicate that questions about a system were asked.
Only facts or observations made by the doctor, or information reported by the patient that the doctor has taken "reasonable steps to verify", not deliberately leaving out relevant information. Plain language, avoiding "abbreviations or medical jargon". [16] The doctor must also have medical records substantiating the certificate.
When Courtney Baker's baby was diagnosed with Down syndrome her doctor advised her to get an abortion -- and now she's opening up about the experience. Mom writes letter to doctor: 'You were wrong ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
Hospitals must give you a moon letter to inform you if you're being observed as an outpatient for more than 24 hours. This affects how much you pay under Medicare.
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When making a medical diagnosis, a lag time is a delay in time until a step towards diagnosis of a disease or condition is made. Types of lag times are mainly: Onset-to-medical encounter lag time, the time from onset of symptoms until visiting a health care provider [14]
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