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AAP News Vol. 13 No. 2 February 1997, p. 21 © 1997 American Academy of Pediatrics
Virtually every physician can remember the first complete history and physical examination he or she performed while learning physical diagnosis. The myriad of new skills to be mastered seemed overwhelming. The challenge was made even greater by having to complete the long, arduous write-up that comprised the medical record. Sorting that information into a sensible format was frustrating and took hours to accomplish, taking nearly as long to master as physical diagnosis itself. Few of us recall our professors saying that the medical record must work for the physician.
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