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WebAll refer to a private medical record that contains systematic documentation of an individual patient’s important clinical data and medical history over time. Accurate, complete … WebNov 28, 2024 · The patient never had it, only the chart did. The same could happen if someone writes the patient has a history of depression, or hypertension, or a stroke in … WebSep 1, 2024 · This is a record of your physical examination of the patient’s condition. It includes observations that can be measured such as body temperature, pulse rate, and blood pressure. It has details of any visible symptoms such as changed skin color or any abnormalities you feel when physically examining the patient. restart computer to default settings