sing
Forum Guru
Topics: 153
Posts: 370
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should i use present tense or past tense for the history notes? it seems all the history notes are present tense in the CSA 40 cases. thanks.
in addition, for a headache patient, if i ask the headache severity in 1-10 scale. and the patient says 5-6. should i write in the history notes that it is a moderately severe headache or need to specify the headache scale is 5-6 in 1-10 scale? thanks.
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| retroviridae
Forum Guru
Topics: 29
Posts: 871
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doesn't matter. Write in point form as it is quicker. For pain, right what the patient says. 5-6/10
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| sing
Forum Guru
Topics: 153
Posts: 370
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thanks a lot.
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