Question

Where to document?

1. information is from patient
2. information from doctor's observation of pt
3. information from objective study
4. information came to light after initial H&P

Answer 1

When documenting information from different sources, it is important to keep track of the sources to credit them and return to them if needed.

Step-by-step explanation:

When documenting information from different sources, it is important to keep track of the sources to credit them and return to them if needed. Here are the different sources:

1. Patient: Information provided directly by the patient should be documented, such as their symptoms or medical history.
2. Doctor's observation: Any information observed by the doctor during their examination of the patient should be documented.
3. Objective study: Information obtained from objective studies or research should be documented. This can include lab results, imaging tests, or other diagnostic procedures.
4. Information after initial H&P: If new information comes to light after the initial history and physical examination, it should be documented.