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Thread: [History] Complete A Medical Record

  1. #1

    Exclamation [History] Complete A Medical Record

    Outline of The Medical Record

    I.Identification
    II.Informant
    III.Chief complaints (CCs)
    IV.History of present illness (HPI)
    V.Past medical and surgical history (PMH)
    A.General health
    B.Chronic illnesses and conditions
    C.Operations and injuries
    D.Hospitalizations
    VI.Family history (FH)
    VII.Social history (SH)
    VIII.Review of systems (ROSs)
    IX.Medications
    X.Allergies and medication intolerances
    XI.Preventive services, including immunizations
    XII.Physical examination (PE)
    XIII.Laboratory and imaging studies
    XIV.Assessment/Problem list
    XV.Plan

    It is the clinician's responsibility to see that the medical record is complete and accurate. Your signature attests to the accuracy of the information and that you have verified it to your satisfaction.

    Once entered and signed, the information in the medical record cannot be altered, although addendum and corrections can be added.

    [History] Complete A Medical Record-screen-shot-2016-04-04-at-9-05-35-pm-png
    [History] Complete A Medical Record-screen-shot-2016-04-04-at-9-06-57-pm-png
    Last edited by admin; Mon 4th April '16 at 9:09pm.
    Clinical Pharmacy Specialist - Infectious Diseases

  2. #2

    Default I.Identification

    These data are frequently provided for the clinician, but should be checked for accuracy.

    Patient's name. Record the complete name, including the family and given names, being careful to obtain correct spelling and birth date. When a married woman who has taken her husband's name, place her husband's given names in parentheses, as Brown, Mary Elizabeth (Mrs. Edward Charles), since she may sign her name as Mrs. Edward C. Brown in correspondence. Determine whether she wishes to be addressed as Ms. or Mrs.

    Sex and gender. Sex is determined by genetics, gender is the patient's sexual identity. Usually, this is obvious, but specific questions asked sensitively may be required.

    Residence. The address should be confirmed and recorded; occasionally, addresses may be needed to distinguish patients with the same name.

    Birth date and age. Record the patient's birth date and stated age. The birth date may be needed to distinguish between patients with the same name.

    Source of referral. When referred, confirm the reason for referral and the name, address, telephone, and FAX numbers of the referring clinician.
    Last edited by Janis.Y.Chen; Mon 11th January '16 at 8:46pm.
    Clinical Pharmacy Specialist - Infectious Diseases

  3. #3

    Default II.The Informant

    Sources of the history. The history is best obtained from the patient with supportive information from others. Record your impression of the historian's accuracy and credibility.

    Interpreters. Try to avoid untrained interpreters. The following is a frequent experience with a lay interpreter, especially a family member. You ask, "Do you have pain?" The interpreter and patient have an animated conversation for a minute or two after which the interpreter says, "No, she doesn't have any pain." It is reasonable to assume that there is uncertainty about the content of the discussion between interpreter and patient. You cannot evaluate the patient's story or answers unless you know how the questions were asked. Your only resource is to ask short concrete questions and insist that the resulting conversation be no longer than you judge necessary.
    Clinical Pharmacy Specialist - Infectious Diseases

  4. #4

    Default III.Chief Complaints (CCs)

    Begin the record with CC, the symptom that precipitated the visit. Complaints should be listed as single words or short phases with the approximate length of time they have been present: for example, nausea for 2 months; vomiting for 1 week. Use the patient's own words free of interpretation. Do not accept a previous diagnosis as a CC; probing may be needed before the patient relates their symptoms rather than their diagnoses or those of previous providers and family members.

    The CC is the starting place for making a differential diagnosis; the details of the symptoms should always be fully elucidated. Since these are the symptoms for which the patient sought care, they will require therapy or an explanation of why therapy is not given. The patient's CC should be the first problem on your problem list. This would seem obvious, but occasionally the physician finds an interesting disease, unrelated to the CC; the medically attractive condition receives all the attention, and the CC is ignored.

    Do not press the patient for a CC too early in the interview. After they have told some of their story, they may be better able to articulate their complaints and concerns. Occasionally, when asked for their symptoms, the patient produces a long detail list of notes. The French label this la malady de petit paper, which may signal an inappropriate level of concern or obsession with their symptoms.
    Last edited by admin; Fri 15th July '16 at 11:32am.
    Clinical Pharmacy Specialist - Infectious Diseases

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    Default IV.History of Present Illness (HPI)

    The HPI is the patient's story of their illness experience; it is the most important part of the diagnostic examination. It should be recorded in complete sentences as a lucid, succinct, and chronologic narrative. Ideally, the HPI should be brief, so that it is easily read and digested, but this is only possible if the history is relatively straightforward. Some stories are complex and the diagnostic possibilities broad, requiring inclusion of more detail since you can't be certain what is pertinent and what superfluous. You must avoid premature interpretation such as replacing their words with medical terminology or failing to record seemingly irrelevant symptoms or events.

    Searching for diagnostic clues. The chief purpose of the history is to help you form diagnostic hypotheses. As the narrative unfold, you should be simultaneously performing three operations: 1.accumulating data (obtaining the history);2.evaluating the data (assessing the meaning of symptoms, seeking more details of time and quantity), and 3.preparing three sets of hypotheses. The hypotheses are anatomic (where is the problem?), physiologic (what is the pathophysiology?), and diagnostic (what diseases could account for this pathophysiology in that place?).

    Symptoms

    A symptom is an abnormal sensation perceived by the patient
    . Insist that the patient describes their symptoms; do not accept diagnoses or medical jargon as a substitute. Record the symptoms using the patient's words. Evaluation of a symptom can be straightforward, as when the patient says, "I've found a lump in my neck" (symptom), and the examiner can palpate a mass (physical sign). However, when the patient complains of a nonspecific symptom, such as chest pain, more information is required. The acronym PQRST is a useful mnemonic; ask about Provocative or Palliative maneuvers, symptom Quality, the Region involved, the Severity, and Temporal pattern of the symptom.

    Question the patient about other symptoms specific for processes and diseases you are considering, either to support or undermine a hypothesis. For example, when the patient complains of chest pain, ask if it is related to respiratory movements. A positive answer prompts questions about inflamed muscles, fractured ribs, and pleurisy. If the answer is negative, ask for an association with exertion or radiation suggestive of angina pectoris. Thus, each step lead to another, resulting in refinement of your hypotheses.

    Clarification. Question the patient until sufficient details are obtained to categorize the symptom. Do not accept vague complaints such as "I don't feel well." If the patient complains of weakness, ascertain if she is weak in one or more muscle groups or if she experiences lassitude, malaise, or myalgia. When a patient says she is dizzy, have her describe the experience without using the word "dizzy." Determine whether shortness of breath occurs at rest or with exertion.

    Quantification. It is good to have the patient quantify the symptoms. For instance, pain cannot be measured, but the severity can be estimated by how it affects the patient. A patient may have a "terrible pain," but if the pain has never interfered with work, sleep, or other activities, "terrible" acquires a clearer meaning. Shortness of breath can be assessed by the amount of exertion required to produce it; for example, ask, "Can you climb a flight of stairs? Can you walk two blocks without stopping?" Neither you nor your reader can interpret what "heavy smoker" means. Heavy varies from one person to another, but smoking 20 cigarettes daily everyone understands. The patient with hemoptysis should estimate the amount of blood lost in household measures, such as teaspoonfuls or cupfuls.
    Last edited by admin; Fri 15th July '16 at 1:35pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

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    Default V.Past Medical and Surgical History

    The past history helps you understand the person you are evaluating and the preconditions that may substantially alter current and future risks for specific health conditions. When relevant, specific facts may be included in the HPI, but they must be recorded again in this section. The significance of past illnesses may only be appreciated after future developments in the patient's condition or as newly recognized disease associations are reported.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

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    Default VI.Family History (FH)

    A FH is essential for all patients receiving more than the most cursory care. This should include four generations, when available: grandparents, patients, aunts and uncles, siblings, and children. For parents and grandparents, record the birth year and current health or age at death and causes. For aunts, uncles, siblings, and children, record the birth year, first name, and current health or cause of death and age at death. Make note of any FH of hypertension, heart disease, diabetes, kidney disease, autoimmune diseases, gout, atopy, asthma, obesity, endocrine disorders, osteoporosis, cancer, hemophilia or other bleeding diseases, venous thromboembolism, stroke, migraine, neurologic or muscular disorders, mental or emotional disturbances, substance abuse, and epilepsy.
    Last edited by admin; Thu 14th January '16 at 2:06pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

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    Default VII.Social History (SH)

    Place of birth. This information may be useful in assessing prevalence of diseases.

    Nationality, ethnicity, and language. It is important to record the patient and family's country of origin and first language(s). English as a second language (ESL) is common in North America and Europe. Ethnic and genetic backgrounds are important in diagnosis of diseases such as hemoglobinopathies and familial Mediterranean fever.

    Marital status. Note whether the patient is single, married, divorced, or widowed, and the duration of marriages or long-term relationships and how they ended.

    Occupations. Some diseases produce symptoms years after exposure, so tabulate past occupations as well as current work. Precise knowledge of the patient's work history sheds light on education, social status, physical exertion, psychologic trauma, exposure to noxious agents, and a variety of conditions that may cause disease. You must ask if an illness is connected with their surroundings and if coworkers have similar symptoms. Always ask about part-time work. For agricultural workers ask about contacts with agricultural chemicals and animals. Determine how much stress accompanies the job, the attitudes of superiors, and the degree of work fatigue.

    Military history. It is important to note military service by branch, geographic locations, discharge (honorable or dishonorable), and eligibility for veteran's benefits.

    Gender preference. Labels, such as heterosexual, homosexual, and bisexual, are often more confusing than helpful. Ask each patient if they have had sex with anyone of the same sex. For example, ask men, "Have you ever had sex with men?" If the patient answers "yes," you should ask further questions about sex with women and the patient's past and current practices and preference. Nonjudgemental inquiry about exchange of sex for drugs, money, or services can dispose high-risk behaviors.

    Social and economic status. Record the patient's year of formal education, vocational training, current living arrangements, and any financial problems.

    Habits. Determine the patient's former and current use of tobacco, coffee, alcohol, sedatives, illicit drugs (especially injection drug use), tattoos, and body piercing.

    Violence and safety. Record the patient's use of vehicle restraints, bicycle and motorcycle helmets, and the presence of home smoke and carbon monoxide alarms.

    Domestic, child, and elder abuse are common problems that go unidentified unless they are asked about explicitly and discreetly. In complete privacy, inquire whether the patient has ever been in a relationship in which she felt unsafe. If the answer is "yes," ask if she feels safe in her current situation. If she answers "no," ask if she wishes you to help her find a safe environment. Never try to explicitly identify the individual whom the patient finds threatening; this information may be volunteered by the patient.

    Prostheses and in-home assistance. Record the patient's use of eyeglasses, dentures and dental appliances, hearing aides, ambulation assistance devices, braces, prosthetic, footwear, and any aide or assistance received in the home.
    Last edited by admin; Thu 14th January '16 at 2:06pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

    Blog: http://www.tomhsiung.com
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    Default VIII.Review of Systems (ROSs)

    The following outline can help inquire for symptoms associated with each system or anatomic region. Symptoms related to the patient's current problem, discovered during your ROS inquiry, should be recorded in the HPI. Become familiar with these symptoms and learn their diagnostic significance: record positive answers and negative responses when they are pertinent to the differential diagnosis. It is efficient to ask the questions while examining the body to which the question pertain. Use of a standardized check in questionnaire will facilitate a thorough review and save time.

    Constitutional. Weight loss or gain, fatigue, fevers, chills, or sweats.

    Skin, hair, and nails.
    • Skin: Color, pigmentation, temperature, moisture, eruptions, pruritus, scaling, bruising, bleeding.
    • Hair: Color, texture, abnormal loss or growth, distribution.
    • Nails: Color changes, brittleness, ridging, pitting, curvature.


    Lymph nodes. Enlargement, pain, tenderness, suppuration, draining sinuses, location.

    Bones, joints, and muscles. Fractures, dislocations, sprains, arthritis, myositis, pain, swelling, stiffness, degree of disability, muscular weakness, wasting or atrophy, night cramps.

    Hemopoietic system. Anemia (type, therapy, and response), lymphadenopathy, bleeding or clotting (spontaneous, traumatic, familial).

    Endocrine system. History of growth, body configuration, and weight; size of hands, feet, and head, especially changes during adulthood; hair distribution; skin pigmentation; goiter, exophthalmos, dryness of skin and hair, intolerance to heat or cold, tremor; polyphagia, polyphagia, polydipsia, polyuria; libido, secondary sex characteristics, impotence, sterility.

    Allergic and immunologic history. Dermatitis, urticaria, angioedema, eczema, hay fever, rhinitis, asthma, conjunctivitis; known sensitivity to pollens, foods, danders, X-ray contrast agents, bee stings; previous skin tests and their results; results of tuberculin tests and others; desensitization, serum, injections, vaccinations, and immunizations.

    Head. Headache, migraine, trauma, syncope, convulsive seizures.

    Eyes. Loss of vision or color blindness, diplopia, hemianopsia, trauma, inflammation, glasses (date of refraction), discharge, excessive tearing.

    Ears. Deafness, tinnitus, vertigo, discharge from the ears, pain, mastoiditis, operations.

    Throat. Hoarseness, sore throats, tonsillitis, voice changes, dysphagia, odynophagia.

    Neck. Swelling, suppurative lesions, enlargement of lymph nodes, goiter, stiffness, and limitation of motion.

    Breasts. Development, lactation, trauma, lumps, pains, discharge from nipples, gynecomastia, changes in nipples, skin changes.

    Respiratory system. Pain, shortness of breath, wheezing, cough, sputum, hemoptysis, night sweats, pleurisy, bronchitis, tuberculosis (history of contacts), pneumonia, asthma, other respiratory infections.

    (Unfinshied)
    Last edited by admin; Thu 14th January '16 at 2:55pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

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