Current Clinical Strategies Gynecology and Obstetrics 2006 Edition Paul D. Chan, M.D. Susan M. Johnson, M.D. Copyright © 2006 Current Clinical Strategies Publishing. All rights reserved. This book, or any parts thereof, may not be reproduced or stored in an information retrieval network without the permission of the publisher. The reader is advised to consult the package insert and other references before using any therapeutic agent. The publisher disclaims any liability, loss, injury, or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this text. Current Clinical Strategies is a trademark of Current Clinical Strategies Publishing Inc. Current Clinical Strategies Publishing 27071 Cabot Road Laguna Hills, California 92653 Phone: 800-331-8227 Fax: 800-965-9420 Internet: www.ccspublishing.com/ccs E-mail:
[email protected] Printed in USA ISBN 1929622-63-5 Surgical Documentation for Gynecology Gynecologic Surgical History Identifying Data. Age, gravida (number of pregnancies), para (number of deliveries). Chief Compliant. Reason given by patient for seeking surgical care. History of Present Illness (HPI). Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), character of pain (constant, intermittent, cramping, radiating); other factors associated with pain (urination, eating, strenuous activities); aggravating or relieving factors. Other related diseases; past diagnostic testi