Table 1: Royal College of Surgeons Criteria for Documentation.
Presenting Complaint | Activities of Daily Living A | Oxygen Saturations | Weight |
History of Presenting Complaint | Alcohol B | Respiratory Rate | Blood Test Results |
Past Medical History | Smoking B | Cardiovascular Examination | Urinary Pregnancy Test D |
Past Surgical History | Employment C | Respiratory Examination | Plan |
Medication History | Systems Review | Abdominal Examination | Advice to patient |
Allergies | Blood Pressure | Neurological Examination | Name |
Family History | Heart Rate | Abbreviated Mental test Score A | Grade |
Package of Care A | Temperature | Height | Time |
AAssessed in over 65 years of age; BAssessed in over 13 years of age; CAssessed between 16 and 70 years of age; DAssessed females 13-50 years of age.