Patient whose x-ray revealed bad case of pneumonia

Reference no: EM133719957

Question

Gabe is finishing his examination of a patient whose x-ray revealed a bad case of pneumonia. He is explaining to his patient that he is going to prescribe penicillin to get rid of the bacteria that is causing the pneumonia. The patient tells Gabe that they are allergic to penicillin. He looks at their medical record again. Their information has been clearly entered by the technician and PA. The record contains the patient's medical history, current medications, chief complaint, and vital signs. Under allergies, the record says, 'None.' What aspect of effective health data is this record missing?

Reference no: EM133719957

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