Based on the following documentation, where would you expect this excerpt to appear?
"The patient is alert and in no acute distress. Initial vital signs: T98, P 102 and regular, R 20 and BP
120/69…"
A. physical exam
B. past medical history
C. social history
D. chief complaint
A The other answer choices represent components of the medical history as supplied by the
patient, while the physical exam is an entry obtained through objective observation and
measurement made by the provider.
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