How to complete a medical chart

Name               Nick Morris                              Age      17               Gender   M   

Date    _______________   

Chief complaint

Medical history

Habits (tobacco, alcohol)

Family history

Surgical history

Medications

Allergies

Physical Exam

1. How does a medical chart help diagnosis and treatment?

1. How might incomplete information on a medical chart cause a misdiagnosis of the problem or condition or delay treatment that could be life-saving? In Nick's case, his friends could provide information on what he had been doing prior to his visit to the Emergency Room. What if Nick's friends could not provide complete information? How would this affect his care?