Documentation should include acquiring information on pre-existing conditions, related prior injury and or treatment, and the event of injury by asking both open-ended and closed questions.
Process/Skill Questions:
- What is the purpose of obtaining a history?
- What are some components of taking a significant history?
- What is the difference between an open-ended and a closed question? Why and when would you use open-ended versus closed questions?
- How are pre-existing conditions, related prior injury and/or treatment, and the event of injury relevant to history?