Question

List two sources within a medical record where the information about present or recent illnesses is most likely to be found.

Answer 1

The two sources within a medical record where the information about present or recent illnesses is most likely to be found are the lab reports and the physician's order. The medical history and physical examination sections of the medical record should contain information about present illnesses. Other possible sources of information are patient referral letters, the discharge summary, and the operative report.