Obtains comprehensive relevant patient data through: (a) interview; (b) correct obtainment of vital signs, which include pain; (c) The use of advanced assessment techniques that is focused or systems approach; (d) correct interpretation of data obtained from monitoring equipment; and (e) correct interpretation of diagnostic results.
Maintains complete, accurate, concise, and updated documentation of patient care. Observes procedures and policies pertaining to any aspect of clinical charting and reporting. […]
Draft the medical abstract of the patient upon his/her request and ensure that it is checked...