Documentation should include acquiring information by asking both open-ended and closed-ended questions regarding

• pre-existing conditions
• related prior injury and/or treatment
• the event of injury
• visual characteristics of the injury.

Process/Skill Questions:

• What is the purpose of obtaining patient history?
• What are some components of taking a significant history?
• What is the difference between an open-ended and a closed-ended question? Why and when would one use open-ended vs. closed-ended questions?
• How are pre-existing conditions, related prior injury and/or treatment, and the event of injury relevant to history?