| A | B |
|---|
| Subjective History | History gathered from the patient. Includes CC, HPI, PMH,PSH,FH,SocHx, ROS |
| Objective Physical Exam | information you gather yourself through your objective observations during the physical exam objective test results. |
| Assessment | Where you rank your differential diagnoses and explain why you propose or rule out each differential by highlighting information from the history and exam already presented. |
| Differential Diagnosis | Possible diagnoses being considered based on information from the history or physical exam. |
| Key components of a Plan | Diagnostic Plan, Therapeutic Plan, Patient Education Plan |
| Diagnostic Plan | a list of what diagnostic tests proposed to help clarify the diagnosis. |
| Therapeutic Plan | A list of what to do to treat the patient. |
| Patient Education Plan | How you can help educate the patient about their condition or how to improve their health |
| Chief Complaint (CC) | The reason the patient is presenting for medical attention now. |
| History of Present Illness (HPI) | Details of the patient's current illness including factors such as onset, palliating, provoking, radiation, severity, timing, associated symptoms related to whay the patient is presenting for medical attention this time. All information in an HPI is PERTINENT to the patient's current illness. |
| Pertinent positive | Patient has a symptom or detail of histo that is pertinent to history of present illness. |
| Pertinent negative | A symptom or detail of history pertinent to the history of present illness that the patient does NOT have. Helps to exclude diagnoses from the differential. |
| Impertinent postive | A symptom that the patient has but is not pertinent to the History of Present Illness. Should be reported as a positive ROS. |
| Impertinent negative | A symptom that the patient does not have that is not pertinent to the history of present illness. Symptoms that you asked but the patient denied and you recognize the symptom would not be pertinent to the history of present illness. |
| Past Medical History (PMH) | illnesses that the patient has been diagnosed or treated for in the past. |
| Past Surgical History (PSH) | Surgical procedures that the patient has had in the past. |
| Allergies section | Medications or foods that the patient had an adverse reaction to in the past. Always note the type of reaction that the patient had. |
| Adverse Reactions | An unpleasant symptom that the patient attributes to a medication or food that they would like to avoid. |
| Examples of Allergic Reactions | Anaphylaxis, Angioedema, Hives, |
| Anaphylaxis | An allergic reaction to a food or medication that causes suddent swelling of the airway and can be quickly deadly by stopping breathing. |
| Examples of Adverse Reactions | rash, nausea, vomiting, diarrhea, oversedation. Unpleasant but not lifethreatening reactions to a food or medication. |
| Medication (section) | LIST of medications the patient takes. Ideally Includes name of medication, strength per tab. and how many tabs are taken. and frequency of each dose. |
| Family History (FH) | Medical problems for each of the patient's first and second degree family members. |
| Social History (Soc Hx) | Details about the patient's habits, abilities, environment, support, that impact the patient'shealth. |
| Review of Systems (ROS) | List of symptoms not pertinent to the HPI that the patient is questioned about. Patient's either report or deny having these impertinent symptoms. |
| Physical Exam (PE) | Objective observations about the patient. |
| Physical Exam (components) | objective findings LISTED in HEAD to TOE ORDER: Vital Signs, General, Head, Eyes, Ears, Nose, Throat. Neck, Cardiac, Respiratory, Abdominal, Genital Urinary, Musculoskeletal, Neurologic, Skin, Psychiatric |
| Review of Systems (components) | List of subjective symptoms the patient can either report or deny having recently. LISTED IN HEAD TO TOE ORDER: General, Head, Eyes, Ears, Nose, Throat, Cardiac, Respiratory, Gastrointestinal, Gential Urinary, Musculoskeletal, Neurologic, Skin, Psychiatric. |
| Where to document?: The patient report chest pain. | If pertinent to why patient is here now report in CC, HPI. If not pertinent to current illness report as + cardiac ROS. |
| Where the document?: Tenderness with palpation of the anterior chest wall. | In the objective physical exam of the chest wall (usually in Cardiac, Pulmonary, or Musculoskeletal system) |
| Where to Document?: The rash was itchy | In the Subjective history (if pertinent to HPI in CC or HPI, if not pertinent to HPI then report in + ROS SKIN. |
| Where to Document?: The rash is surrounded by excoriations. | In the Objective Physical Exam Skin section. |
| What format is used for the HPI? | paragraph that tells the patient's story. |
| What format is used for the PMH? | A LIST with dates noted when possible. |
| What format is used for the PSH? | LIST with dates noted when possible. |
| What format is used for the Review of Systems (ROS)? | a LIST of symptoms organized by organ system in head to toe order. |
| What format is used for the Physical Exam (PE)? | A LIST of objective description organized in head to toe order. |
| Where to document?: The patient's chest pain is most likely due to myocardial infarction. | Assessment section. |
| What format is used for Assessment | Can be in paragraph or list format. |
| Problem List | LIST of current active problems organized from most important to least important. |
