• Include age, sex, race, occupation

• Who provided history

Chief Complaint (CC): or reason for admission and duration of symptom/sign

Can be:

• a symptom – may wish to use patient’s own words 

• a sign – e.g., swelling of ankles 

• an abnormal lab finding e.g. hypokalemia 

• a diagnosis – e.g., acute anterior myocardial infarction 

History of Present Illness (HPI): 

If the patient was previously well and presents with an acute problem, use this format: 

1. What is the problem that brought the patient to the hospital? This will generally be a symptom or sign. What, if anything were the precipitating circumstances, illness or injury?

2. Clarification of the presenting symptom or sign (e.g.,): 

   • nature

   • onset 

   • location/radiation 

   • modifying factors 

     • what makes it better 

     • what makes it worse 

   • associated symptoms 

   • course of events from onset up to the time of admission to hospital (including investigations and treatment already carried out) 

   • specific reason(s) for hospitalization at this time (if known) 

3. A review of the system or systems involved. This review act as a back-up or safety check list to insure that all important questions about the involved system(s) are addressed, and to elicit any other important symptoms etc., that may aid in formulating a differential diagnosis and plan for management. (This section is part of the HPI, and should not be given a separate heading). 

Many patients now admitted to teaching hospitals do not follow the pattern described above. Most patients we see have one or more serious chronic medical problems, and are hospitalized when they develop an acute exacerbation or complication of their chronic illness. For these types of patients the following format can be more effective:

HPI

1. What is the chronic illness involved and when did it first start? 

2. What has been the course of that illness over the years? 

   • past treatment 

   • previous complications 

   • previous hospitalizations 

   • specify when and where the last admission occurred, the reason, and specific management given. 

3. How has the patient been managed subsequently (e.g., what treatment has the patient been maintained on since the last hospitalization)? 

4. The recent events up to this hospitalization and the specific reasons for this hospitalization. 

5. The review of systems for the system and systems involved. 

When patients have multiple problems all contributing to this hospitalization, the HPI can be handled in one of two ways:

• handle each major problem as above but separately. 

• Select one problem only for the HPI, and document the others in the appropriate section of the ROS. 

Review of Systems (ROS):

This covers the other systems which have not already been addressed in the HPI. Again the ROS serves as a check list to identify any other symptoms, signs, diagnoses or problems that may play a role in the diagnosis or management of the patient. Various references use different headings. As a rule it is easier to remember where you are if you start from the head and go through to the toes, as on the physical exam. Later on you should be able to cover the ROS while performing the physical exam. General systems not included in the HPI can be listed at the beginning or at the end of the ROS. The following headings can be used when recording the ROS:

• HEENT 

• Endocrine 

• Chest 

• CV 

• GI 

• GU 

• Musculoskeletal 

• Neurology 

• Integument 

• General/Psych 

Past Medical History (PMH):

• any parts of the history not already covered in the HPI or ROS.

• remember in Medicine we are usually dealing with chronic diseases like COPD, CAD. Therefore, past events like MI’s and pneumonias usually are part of these ongoing processes and belong in the HPI or ROS. 

Social History:

• Stress points that may be a factor in the patient’s diagnosis, treatment, or rehabilitation (e.g., home situation/employment). 

Family History:

Often best to use a diagram especially in cases where it may aid in diagnosis or management.

Allergies:

If patients say they are allergic, ask for a description. In most cases they have had an adverse reaction or side effect, not an allergy.

Medications:

Include over the counter, prescribed, homeopathic.

Begin with a brief (i.e.) 2 line description of the patient; note if in distress. 

If a neurologic case, comment on: 

• • Level of consciousness 

  • Alert, drowsy, obtunded, unresponsive 

  • Orientation x 1, 2, or 3 (person, time, place) 

  • Ability to communicate 

  • Appropriateness of mentation 

VITAL SIGNS: 

Pulse rate, regular or not; BP; temperature or afebrile; RR; Wt (if possible); Ht (if possible). 

Test Results: 

Include lab results/X-rays that help define the problems (renal panel, CBC, glucose, CXR and EKG) 

Problem List: 

1. No admission history and physical examination is complete until: 

2. In descending importance, each problem identified is listed together with: 

   • a differential diagnosis 

   • a plan for investigation to clarify the diagnosis of each problem 

   • a plan for the management of each problem 

3. The first problem listed should address the chief complaint of reason for admission 

4. The problem list should be maintained (with appropriate revisions as diagnosis are clarified) throughout the hospital admission and will form the basis for both the progress notes and the discharge summary.