SUBJECTIVE DATA—THE HISTORY
Subjective data are the positive and negative pieces of information that the patient offers. Record the patient’s history, especially during an initial visit, to provide a comprehensive database. Arrange information appropriately in specific categories, usually in a particular sequence such as chronologic order with most recent information first. Include both positive and negative data that contribute to the assessment. Use the following organized sequence as a guide.
Record data recommended by health care facility.
Identification number/social security number
Address (home and business)
Insurance plan, number
Date of visit
For children and dependent adults, names of parents or next of kin
Put identifying information on each page of record.
SOURCE AND RELIABILITY OF INFORMATION
Document who is providing the history and relationship to patient.
Indicate when an old record is used.
State judgment about reliability of information.
CHIEF CONCERN/PRESENTING PROBLEM/REASON FOR SEEKING CARE
Description of patient’s main reasons for seeking health care, in patient’s own words with quotation marks. Paraphrase only if this makes the patient’s concern more clear.
Include duration of problem.
HISTORY OF PRESENT PROBLEM
List and describe current symptoms of chief concern and their appearance chronologically in reverse order, dating events and symptoms.
List any expected symptoms that are absent.
Identify anyone in household with same symptoms.
Note pertinent information from review of systems, family history, and personal/social history along with findings.
Where more than one problem is identified, address each in a separate paragraph, including the following details of symptom occurrence:
Onset: When problem first started, chronologic order of events, setting and circumstances, manner of onset (sudden versus gradual)
Location: Exact location, localized or generalized, radiation patterns
Duration: How long problem has lasted, intermittent or continuous, duration of each episode
Character: Nature of symptom
Aggravating/associated factors: Food, activity, rest, certain movements; nausea, vomiting, diarrhea, fever, chills, etc.
Relieving factors: Prescribed treatments and/or self-remedies, alternative or complementary therapies, their effect on the problem; food, rest, heat, ice, activity, position, etc.
Temporal factors: Frequency; relation to other symptoms, problems, functions; symptom improvement or worsening over time
Severity of symptoms: Quantify on a 0 (minimal) to 10 (severe) scale; effect on patient’s lifestyle
List and describe each of the following with dates of occurrence and any specific information available:
General health and strength over lifetime as patient perceives it; disabilities and functional limitations
Hospitalization and/or surgery: Dates, hospital, diagnosis, complications
Injuries and disabilities
Major childhood illnesses
Adult illnesses and serious injuries
Immunizations: Polio, diphtheria-pertussis-tetanus, tetanus toxoid, hemophilus influenza type b, hepatitis A and B, measles, mumps, rubella, varicella, Prevnar, influenza, anthrax, smallpox, cholera, typhus, typhoid, meningococcal, pneumococcal, bacille Calmette-Guérin (BCG), last purified protein derivative (PPD) or other skin tests, unusual reaction to immunizations
Medications: Past, current, recent medications (prescribed, nonprescription, complementary therapies, home remedies); dosages
Allergies: Drugs, foods, environmental
Transfusions: Reason, date, number of units transfused, reactions
Emotional status: History of mood disorders, psychiatric attention or medications
Recent laboratory tests (e.g., glucose, cholesterol, Pap smear, mammogram, prostate-specific antigen)
Present information about age and health of family members in narrative or pedigree form, including at least three generations.
Family members: Include parents, grandparents, aunts and uncles, siblings, spouse, children. For deceased family members, note age at time of death and cause, if known.
Major health or genetic disorders: Include hypertension; cancer; cardiac, respiratory, kidney, or thyroid disorders; strokes; asthma or other allergic manifestations; blood dyscrasia; psychiatric difficulties; tuberculosis; diabetes mellitus; hepatitis; or other familial disorders. Note spontaneous abortions and stillbirths.
Include information according to concerns of patient and influence of health problem on patient’s and family’s life:
Cultural background and practices, birthplace, position in family
Religious preference, religious or cultural proscriptions for medical care
Home conditions: Economic condition, number in household, pets, presence of smoke detectors, presence and security of firearms
Occupation: Work conditions and hours, physical or mental strain, protective devices used; exposure to chemicals, toxins, poisons, fumes, smoke, asbestos, or radioactive material at home or work
Environment: Home, school, work; structural barriers if handicapped, community services utilized; travel; exposure to contagious diseases
Current health habits and/or risk factors: Exercise; smoking; salt intake; weight control; dental hygiene diet, vitamins and other supplements; caffeine-containing beverages; alcohol or recreational drug use; response to CAGE, TACE, or RAFFT questions (see Appendix) related to alcohol use; participation in a drug or alcohol treatment program or support group
Sexual activity: Protection method, contraception
General life satisfaction, hobbies, interests, sources of stress, adolescent’s response to HEEADSSS questions (see Appendix)
REVIEW OF SYSTEMS
Organize in general head-to-toe sequence, including an impression of each symptom.
Record expected or negative findings as absence of symptoms or problems.
When unexpected or positive findings are stated by patient, include details from further inquiry as you would in the present illness.
Include the following categories of information (sequence may vary):
General constitutional symptoms
Skin, hair, nails
Head and neck
Eyes, ears, nose, mouth, throat
Heart and blood vessels
Chest and lungs
OBJECTIVE DATA—PHYSICAL FINDINGS
Objective data are the findings resulting from direct observation—what you see, hear, and touch.
Age, race, gender, general appearance
Nutritional status, weight, height, frame size, body mass index
Vital signs: Temperature, pulse rate, respiratory rate, blood pressure (two extremities, two positions)
Physical appearance and behavior
Cognitive: Memory, reasoning, attention span, response to questions
Speech and language: Voice quality, articulation, content, coherence, comprehension
Emotional stability: Anxiety, depression, disturbance in thought content
Color, integrity, temperature, hydration, tattoos, scars
Presence of edema, excessive perspiration, unusual odor
Presence and description of lesions (size, shape, location, inflammation, tenderness, induration, discharge), parasites
Hair texture and distribution
Nail configuration, color, texture, condition, presence of clubbing, nail plate adherence, firmness
Size and contour of head, scalp appearance and movement
Facial features (characteristics, symmetry)
Presence of edema or puffiness, tenderness
Temporal arteries: Characteristics
Visual acuity, visual fields
Appearance of orbits, conjunctivae, sclerae, eyelids, eyebrows
Pupillary shape, consensual response to light and accommodation, extraocular movements, corneal light reflex, cover-uncover test
Ophthalmoscopic findings of cornea, lens, retina, optic disc, macula, retinal vessel size, caliber, and arteriovenous crossings
Configuration, position and alignment of auricles
Otoscopic findings of canals (cerumen, lesions, discharge, foreign body) and tympanic membranes (integrity, color, landmarks, mobility, perforation)
Hearing: Air and bone conduction tests, whispered voice, conversation
Appearance of external nose, nasal patency, flaring
Nasal mucosa and septum, color, alignment, discharge, crusting, polyp
Appearance of turbinates
Presence of sinus tenderness or swelling
Discrimination of odors
MOUTH AND THROAT
Number, occlusion and condition of teeth; presence of dental appliances
Lips, tongue, buccal and oral mucosa, floor of mouth (color, moisture, surface characteristics, ulcerations, induration, symmetry)
Oropharynx, tonsils, palate (color, symmetry, exudate)
Symmetry and movement of tongue, soft palate and uvula; gag reflex
Discrimination of taste
Mobility, suppleness, strength
Position of trachea
Thyroid size, shape, tenderness, nodules
Presence of masses, webbing, skinfolds
Size and shape of chest, anteroposterior versus transverse diameter, symmetry of movement with respiration
Presence of retractions, use of accessory muscles, diaphragmatic excursion
Respiratory rate, depth, regularity, quietness or ease of respiration
Palpation findings: Symmetry and quality of tactile fremitus, thoracic expansion
Percussion findings: Quality and symmetry of percussion notes, diaphragmatic excursion
Auscultation findings: Characteristics of breath sounds (pitch, duration, intensity, vesicular, bronchial, bronchovesicular) unexpected breath sounds
Characteristics of cough
Presence of friction rub, egophony, whispered pectoriloquy
Size, contour, venous patterns
Symmetry, texture, masses, scars, tenderness, thickening, nodules, discharge, retraction, or dimpling
Characteristics of nipples and areolae
Anatomic location of apical impulse
Heart rate, rhythm, amplitude, contour
Palpation findings: Pulsations, thrills, heaves, or lifts
Auscultation findings: Characteristics of S1 and S2 (location, intensity, pitch, timing, splitting, systole, diastole)
Presence of murmurs, clicks, snaps, S3 or S4 (timing, location, radiation intensity, pitch, quality)
Blood pressure: Comparison between extremities with position change
Jugular vein pulsations and distention, pressure measurement
Presence of bruits over carotid, temporal, renal, and femoral arteries, abdominal aorta
Pulses in distal extremities
Temperature, color, hair distribution, skin texture, nail beds of lower extremities
Presence of edema, swelling, vein distention, Homans sign, or tenderness of lower extremities
Shape, contour, visible aorta pulsations, venous patterns, hernia
Auscultation findings: Bowel sounds in all quadrants, character
Palpation findings: Aorta, organs, feces, masses, location, size, contour, consistency, tenderness, muscle resistance
Percussion findings: Areas of different percussion notes, costovertebral angle tenderness
Appearance of external genitalia and perineum, distribution of pubic hair, inflammation, excoriation, tenderness, scarring, discharge
Internal examination findings: Appearance of vaginal mucosa, cervix, discharge, odor, lesions
Bimanual examination findings: Size, position, tenderness of cervix, vaginal walls, uterus, adnexa, ovaries
Rectovaginal examination findings
Urinary incontinence with bearing down
Appearance of external genitalia, circumcision status, location and size of urethral opening, discharge, lesions, distribution of pubic hair
Palpation findings: Penis, testes, epididymides, vasa deferentia, contour, consistency, tenderness
Presence of hernia or scrotal swelling
ANUS AND RECTUM
Sphincter control, presence of hemorrhoids, fissures, skin tags, polyps
Rectal wall contour, tenderness, sphincter tone
Prostate size, contour, consistency, mobility
Color and consistency of stool
Presence of lymph nodes in head, neck, epitrochlear, axillary, or inguinal areas
Size, shape, consistency, warmth, tenderness, mobility, discreteness of nodes
Posture: Alignment of extremities and spine, symmetry of body parts
Symmetry of muscle mass, tone and muscle strength; grading of strength, fasciculations, spasms
Range of motion, passive and active; presence of pain with movement
Appearance of joints; presence of deformities, effusions, warmth, tenderness, or crepitus
Cranial nerves: Specific findings for each or specify those tested, if findings are recorded in head and neck sections
Cerebellar and motor function: Gait, balance, coordination with rapid alternating motions
Sensory function, symmetry (touch, pain, vibration, temperature, monofilament)
Superficial and deep tendon reflexes: Symmetry, grade
The assessment section is composed of your interpretations and conclusions, their rationale, the diagnostic possibilities, and present and anticipated problems—what you think.
For each new and existing problem on the problem list, make a differential diagnosis list with rationale based on subjective and objective data. Describe disease progression or complication.
The plan describes the need to invoke diagnostic resources, therapeutic modalities, and other resources and the rationale for these decisions—what you intend to do.
Diagnostic tests ordered or performed
Therapeutic treatment plan
Future visit to evaluate plan