Essentials
Patient Name Other Data – DOB, Date, MRN Site of care History Source Reliability
Chief Complaint (CC)
A short description of the presenting problem Remember OPQRST: Onset, Palliate/Provoke, Quality, Region/Radiation, Symptoms (associated), Temporal aspects.
History of Present Illness
Opening statement: Chief complaint in light of the patient’s clinical context Elaborate description of the chief complaint Accompanying symptomatology Absent pertinent symptomatology Pertinent PMHx, Family Hx, Social Hx Concluding statement: How the patient got to the care site
Past Medical History (PMHx)
Past illnesses or medical problems (when problem was diagnosed, its current treatment and status) Prior hospitalizations or visits to the emergency room or urgent care Prior childhood illnesses
Medical Care
Immunizations against common diseases (flu, pneumonia, mumps, measles, whooping cough, tetanus, etc)
At this point in their training, students will not know the vaccine schedule, but they should know to ask if a patient/family knows if they are missing any vaccines and to ask for the vaccine card so they can confirm
Age appropriate screening tests (mammograms, colonoscopies, Pap smears, etc.) Similarly, students may not know age-appropriate screening tests
Surgical History
Prior surgical procedures (type of procedure, where and if it is an office or hospital procedure, complications especially to anesthesia, duration of recovery period)
Psychiatric History
Psychiatric illnesses or diagnoses including prior hospitalization and treatment, any suicidal thoughts (suicidality) or past attempts, depression
Obstetric/Gynecologic History
Last menstrual period (regularity of cycles, duration, heaviness of bleeding, pads/tampons used daily) Number and outcomes of pregnancies, birth experiences, type of delivery (surgical/vaginal), abortions, still births and premature deliveries
Current Medications
Prescription, OTC, herbal remedies Transfusions, radiation, acupuncture
Allergies
To medications, food, animals, latex Include description of allergic reaction
Family History
Outline/diagram with age & health of siblings, parents, grandparents +/- Specific family illnesses, i.e. hypertension, diabetes, cancer, heart disease, asthma, others
Social History
General (Place of birth, years in U.S., significant travel, military service, previous exposures (environmental and infectious, such as asbestos) Level of education (school, focus of studies/degree, financial support, behavioral issues) Occupation/Work (type, work days and time, multiple jobs, satisfaction) Home environment (household members, domicile, access, safety) Basic and Instrumental Activities of Daily Living (independence or assistance to dressing, eating, ambulation, transferring, hygiene, finance, travel, cooking/food preparation, laundry, housekeeping) Tobacco - smoking, chewing (current or past, type, how many, how often, any previous attempts to quit, determine pack-years, assess willingness to quit) Alcohol (type, quantity, frequency, CAGE Screening: Cut down/Annoyed by people criticizing drinking/Guilty/Eye-opener) Drug abuse (type and route of use, duration, prior attempts to quit, history of arrests or incarceration Nutrition (typical daily diet, self-preparation or delivery, include beverage such as coffee/tea) Exercise/Physical Activity (how much, how often, what types) Social Support (status of relationship to family members, caregivers, friends; degree and frequency of communication; level of involvement) Spirituality (what their faith/belief, degree and importance to patient, interaction with community) Sexual activity: men/women/or both Marital status, children, abortion, miscarriage Number of partners, contraception STI history and prevention