2.10 Sample Documentation

Open Resources for Nursing (Open RN)

Information obtained during a health history interview is typically documented on agency-specific forms. See “Chapter Resources A” for a sample health history form used for documentation purposes. Additional information collected that is not included on the form should be documented in an associated progress note.

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Nursing Skills Copyright © 2021 by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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