Re: HIM form question


it depends on the institution's policies. where i have worked (i assume you are looking at hospital records) we gathered about 8 pages of info on every patient. vital signs, name, birthdate, reason for admission, a full assessment of physical and mental condition, how to contact relatives, nutritional info, medication list, allergies, and initial orders from the doctor. there may be more, but that's what i remember off the top of my head.