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Chapter 3 Medical History & Patient Assessment

Horizontales
Noted by a mark on the DNA for a specific illness or disease
Using technical or medical terminology when talking with patient
Subjective information- indications of disease or changes in the body as sense by the patient
Objective information that can be observed or perceived by someone other than the patient
Verticales
One statement describing the signs and symptoms that led the patient to seek medical care, is document in the patient medical record at each visit
Record containing information about patient past and present health status
Federal law that protects the privacy of health information