Chief complaint: Current problem in patient’s own words

 

History of present illness (HPI):

Description of symptoms the patient is currently experiencing guide with attention to onset, frequency, duration, progression, quality, quantity, anatomic location, radiation, aggravating, alleviating, and associated factors, patient’s perception of contributing external stressors, and effect of illness on daily life.

The information is presented in chronological order and includes prior and diagnostic tests, related history, previous treatments for the problem, risk factors, family history, medications, and pertinent review of systems relevant to the differential diagnosis.

Other significant ongoing problems should be included in the HPI in a separate paragraph in detail if they relate to the chief complaint.

 

Health History:

• Current medications
  • Prescribed
  • Herbal supplements
  • Over-the – counter
  • Supplements
  • Vitamins

 

• Allergies
  • Drugs and environment, including manifestations

 

• Operations
• Hospitalizations
• Transfusions
  • Type of blood product
  • Number of units
  • Adverse reactions
• Trauma
• Current stable problems
• Past problems unrelated to the HPI that have resolved
• Documentation that adult patients have been questioned about the following illnesses
  • Usual childhood illnesses or immunizations according to CDC guidelines
  • Anemia
  • Asthma
  • Anxiety and depression
  • Bleeding disorders
  • Cancer
  • Diabetes
  • Elevated lipids
  • Emphysema
  • Hepatitis
  • HIV
  • Hypertension
  • Kidney disease
  • Liver
  • Myocardial infarction
  • Peptic ulcer disorder
  • Stroke
  • Sexually transmitted infections
  • Thyroid
  • Tuberulosis
  • Health maintenance according to USPSTF guidelines or other expert guidelines

 

Family history: Genogram

 

Psychosocial history

• Patient profile
  • Beliefs as related to health
  • Marital status
  • Children
  • Past or present employment
  • Sexual orientation
  • Insurance
  • Financial support
  • Education
  • Religion
  • Hobbies
  • Household composition
  • Sleep
  • Leisure
  • Stressors and support

 

• Lifestyle risk factors
  • caffeine
  • Tobacco
  • Alcohol
  • Substance abuse
  • Diet and exercise

 

Review of systems

• General
• Skin
• Head
• Eyes
• Ears
• Nose
• Mouth and throat
• Neck
• Breast
• Respiratory
• Cardiovascular
• Genitalia
• Endocrine
• Musculoskeletal
• Peripheral vascular
• Hematologic
• Neurologic psychiatric

 

Physical examination

• Vital signs
• General
• Skin
• Lymph nodes
• HEENT
• Neck
• Chest
• Heart
• Breast
• Abdomen
• Genitalia
• Musculoskeletal
• Peripheral vascular
• Neurologic
  • Mental status exam
  • Cn exam
  • Cerebellum
  • Sensory
  • Reflexes

 

Diagnostic tests

• Laboratory tests
• Imaging or other information.

 

Impression

• For each new or undifferentiated problem or symptom, create a comprehensive list of possible diagnoses from most likely to least likely.
• For each ongoing problem, separately discuss the status of each condition. This forms the basis for ongoing care.
• If appropriate state the status of ongoing problems and the continued plan of care
• For each identified acute or self-limiting diagnosis, state the resolution and note the problem is inactive and you do not need to address ongoing care
• Health maintenance and immunizations should be addressed according to established guidelines if appropriate.

 

ICD 10 codes

 

Plan: For all active problems address the following as appropriate

• Diagnostic tests
• Therapeutic interventions
• Counseling and education
• Health care maintenance
• Referrals
• Follow up

 

Competency defense

            List eh Competency you have used and defend its use in narrative form

 

 

 

Medications

Box out all medications

Include

Drug

Dose range

Method of administration

Mechanism of action

Clinical use

Side effects