【正确答案】正确答案： A detailed, current medical record can be an invaluable asset for patient evaluation. When recording the history and physical, the physician should follow several rules: 1. Record all pertinent data. 2. Avoid extraneous data. 3. Use common terms. 4. Avoid nonstandard abbreviations. 5. Be objective. 6. Use diagrams or pictures when indicated. Also fluid intake and urine output is often recorded and should be noted and reported on rounds. Other important information sought from the nurses notes include any recorded incidents during the last 24 hrs, such as record of pain episodes, GI distress such as vomiting or diarrhea, febrile episodes or episodes of confusion. When writing progress notes, it"s helpful to follow the SOAP format S=subjective —This section usually includes a description of patient complaints and symptoms. O=objective — This section records pertinent patient physical exam findings including vital signs as well as pertinent recent x-ray, lab and biopsy data. A=assessment—A differential diagnosis should be included in this section for problems that have not been clearly elucidated. P=plan—In this section is recorded the treatment plan including estimated length of treatment, and discharge plans.
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