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Primary Clinical Skills: General

General

Documentation Example for Constitutional:

  1. Healthy-appearing, well-groomed and cheerful.
  2. Ill-appearing, looks pale, alert but unable to speak in sentences due to SOB.
  3. Appears older than stated age, pleasant.
  4. Appears anxious, moving in chair throughout interview, playing with hands constantly.
  5. Ill-appearing, unable to stay awake to answer questions, arousable but falls back asleep quickly.

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