... Brief History, Pertinent Physical Examination, and Laboratory Data: Describe the course of the patient's disease up until the time that the patient came to the hospital, including physical exam and ... (inputs and outputs), including oral, parenteral, urine, and stool volumes Physical exam, including chest and abdomen, with particular attention to active problems Emphasize changes from previous physical ... Internet: www.ccspublishing.com/ccs Printed in USA ISBN 1-929622-28-7 Medical Documentation History and Physical Examination Identifying Data: Patient's name; age, race, sex List the patient’s...