Demonstration should include
- investigating the chief complaint
- assessing the mechanism of injury or nature of illness
- soliciting and recording a patient’s past medical history, including signs/symptoms, allergies, medications, pertinent past history, last oral intake, events leading to injury or illness (SAMPLE) and onset, provocation, quality, radiation, severity, timing (OPQRST).
Process/Skill Questions:
- How does the mechanism of injury or nature of illness change the questions that are included when an EMR is investigating the chief complaint?
- How does a patient’s chief complaint (medical or trauma) change when a patient history is performed within the assessment sequence?