PATIENT CHART

INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10. LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS Patient Name, Age, Gender, Status,

2.  CHIEF COMPLAINT (CC) Address, Occupation, Religion
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10. LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

Indicate the reason of admission
2.  CHIEF COMPLAINT (CC) to the hospital in the words of the
3.  HISTORY OF PRESENT ILLNESS (HPI) informant.
4.  PAST MEDICAL HISTORY (PMH)
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10. LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

Example:
2.  CHIEF COMPLAINT (CC) “I’m having pain in my leg.”
3.  HISTORY OF PRESENT ILLNESS (HPI) “I was not feeling well, and I think I
4.  PAST MEDICAL HISTORY passed out.”
“My right arm feels like it’s frozen. I
5.  FAMILY HISTORY
can barely move it.”
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10. LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.Carson
PAST MEDICAL
Johnson HISTORY African-American man admitted in the
is a 67-year-old
5.emergency
FAMILYroom HISTORY
at 8:45 AM after noticing a sudden onset of weakness
6.in his
SOCIAL HISTORY
right arm. He woke up at 7:15 AM and went to the bathroom to
7.brush
MEDICATIONS, ALLERGIES,
his teeth. While walking from theIMMUNIZATIONS
bathroom to the kitchen, he
8.noticed
REVIEWgeneralOFweakness
SYSTEMS and had trouble saying “good morning” to his
(ROS)
9.son,THE
with whom he lives.
PHYSICAL His son immediately brought him to the ER.
EXAMINATION
While
10. in the ER, he started
LABORATORY TESTto have a rightsided facial droop. He
denied
11. THEany dizziness, LIST
PROBLEM vomiting, or headache.
12. THE PLAN
 INFORMATION IN PATIENT
CHART

A chronologic description of the

1.  PATIENT DEMOGRAPHICS development of the Pt's present
2.  CHIEF COMPLAINT (CC) illness
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10.  LABORATORY TEST
11.  THE PROBLEM LIST
12.  THE PLAN
 1. PATIENT DEMOGRAPHICS
INFORMATION IN PATIENT
CHART

1.  PATIEN DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)

This is the first admission for this 13-month-old white boy who was felt to be well
until approximately 3 weeks ago when his stools became loose and frequent.
This problem persisted with three to four stools daily until three days ago when
he developed a fever (documented only by his mother's feeling that he was
warm). The stools became green and "slimy" although the frequency remained
unchanged. His intake of fluids consisted of three 3-oz. bottles of whole milk. No
solids were tolerated.On the day of admission the baby did not take any
feedings. He vomited twice admitted to the hospital. No fever was noted. His
responsiveness had decreased to the point of unresponsiveness. On arrival in
the emergency room he was immediately given an intravenous bolus of normal
saline and admitted to the ward.
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
prior illnesses, their treatments
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10.  LABORATORY TEST
11.  THE PROBLEM LIST
12.  THE PLAN
 INFORMATION IN PATIENT
CHART

In 1996, Lucy experienced a

1.  PATIENT DEMOGRAPHICS
2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNI
ZATION
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10.  LABORATORY TEST
11.  THE PROBLEM LIST
12.  THE PLAN
minor stroke, which caused
temporary paralysis in her left
arm. She was monitored in
hospital for three weeks and
recovered.
3 years ago, Lucy was diagnosed
as lupus carrier. Since the
diagnosis,SLucy has been taking
Warfarin and she expects to
maintain Warfarin therapy for life.
Her condition has exacerbated a
series of endotheliopathies,
predisposing Lucy to retinal
microvascular occlusion.
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY present health or cause of death
5.  FAMILY HISTORY of parents, brothers, sisters.
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10. LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
marital status, past and present
4.  PAST MEDICAL HISTORY occupations, travel, hobbies,
5.  FAMILY HISTORY stresses, diet, habits, and use of
6.  SOCIAL HISTORY tobacco, alcohol, or drugs
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10. LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI) List any medications
4.  PAST MEDICAL HISTORY prescription, including
5.  FAMILY HISTORY over-the-counter
medications, home
6.  SOCIAL HISTORY
remedies, vitamins, and
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS supplements as well.
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10. LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS) An organized and
9.  THE PHYSICAL EXAMINATION complete examination of
10.  LABORATORY TEST a Pt's organ system
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
Do you have any problems
7.  MEDICATIONS, ALLERGIES, IMMUNIZATI ON
breathing? Do you have
8.  REVIEW OF SYSTEMS (ROS) Sshortness of breath when
9.  THE PHYSICAL EXAMINATION exercising, walking,
climbing the stairs?”
10.  LABORATORY TEST
11. THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATION
8.  REVIEW OF SYSTEMS (ROS) Patient states his chest hurts
9.  THE PHYSICAL EXAMINATION when he coughs, but not
10.  LABORATORY TEST when he takes a deep breath.
No SOB. No complaints of
11.  THE PROBLEM LIST
pain in joints. No problems
12. THE PLAN sleeping.
 INFORMATION IN PATIENT
CHART

Skin: bruising, discoloration, pruritus, birthmarks, moles, ulcers, changes in the hair or
1. sun
nails, PATIENT
exposureDEMOGRAPHICS
and protection.
Ears: tinnitus, change
2. CHIEF in hearing,(CC)
COMPLAINT running or discharge from the ears, deafness, dizziness.
Eyes
3. :change
HISTORY in vision, pain, inflammation,
OF PRESENT ILLNESS infections,
(HPI) double vision, scotomata, blurring,
tearing.
4. PAST
mouth MEDICAL
and throat :dentalHISTORY
problems, hoarseness, dysphagia, bleeding gums, sore throat,
5. FAMILY
ulcers or sores inHISTORY
the mouth.
nose
6. and sinuses
SOCIAL discharge, epistaxis, sinus pain, obstruction.
HISTORY
breasts pain, change in contour
7. MEDICATIONS, or skin color,IMMUNIZATIONS
ALLERGIES, lumps, discharge from the nipple.
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10.  LABORATORY TEST
11.  THE PROBLEM LIST
12. THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION A physical examination is an
evaluation of the body and its
10.  LABORATORY TEST
functions using inspection,
11.  THE PROBLEM LIST palpation , percussion , and
12.  THE PLAN auscultation .
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
A generic term for any test
10.  LABORATORY TEST regarded as having value in
11.  THE PROBLEM LIST assessing health or disease states.
12.  THE PLAN
 INFORMATION IN PATIENT
CHART

1.  PATIENT DEMOGRAPHICS

2.  CHIEF COMPLAINT (CC)
3.  HISTORY OF PRESENT ILLNESS (HPI)
4.  PAST MEDICAL HISTORY
5.  FAMILY HISTORY
6.  SOCIAL HISTORY
7.  MEDICATIONS, ALLERGIES, IMMUNIZATIONS
8.  REVIEW OF SYSTEMS (ROS)
9.  THE PHYSICAL EXAMINATION
10.  LABORATORY TEST any health care condition that
11.  THE PROBLEM LIST requires diagnostic, therapeutic, or
educational action
12.  THE PLAN