Medical History

  Each detainee chart contains documentation for medical histories:
• Medical History Document (sometimes referred to as a 14-Day Assessment)
• Extended Medical History Document (history document with additional area for physical assessment, mental health status and education)
• Physical Exam
• Intake Screening
• TB test (an area to document TB test placement and results)
• Immunization record (area to document past or current immunizations)

  History documents, Physical Exam, Intake Screening and TB test may all be linked to a workflow with reminders automatically generated on the Nurse’s Task List.



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