Document the history of an injury.

Documentation should include acquiring information by asking both open-ended and closed question regarding

  • pre-existing conditions
  • related prior injury and/or treatment
  • the event of injury.

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 one use open-ended vs. closed questions?
  • How are pre-existing conditions, related prior injury and/or treatment, and the event of injury relevant to history?