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History and Physical
documents of patient history and physical examination findings |
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History
record of subjective information regarding patient medical history, including past injuries, illnesses, operations, defects, and habits |
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Chief complaint
description of what brought the patient to the hospital; brief or patient own words with quotes |
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History of present illness (present illness)
Amplification of chief complaint recording details of the duration and severity of the condition |
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past medical history (past history)
a record of information about the patients past illnesses starting with childhood, including surgical operations injuries, physical defects, medications, and allergies |
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usual childhood diseases
an abbriviation to note that the patient had the usual illnesses during childhood |
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Family history
state of health of immediate family members
A&W- alive and will
L&W- living and well |
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Social history
a record of patients recritional intrests, hobbies, and use of tobacco and drugs, including alcohol |
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Occupational History
a record of work habits thta may involve work related risks |
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| Review of systems (systems review) |
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physical exmination
documentation of a physical examination of a patient, inclucing nitations of positive and negitive findings |
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| head, eyes, ears, nose, throat |
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| no acute distress, no appriciable disease |
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| pupils equal, round, and reactive to light and accommodation |
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Assessment
identifacation of a disease or condition after evaluation of the patients history, symptoms, signs, and result of lab tests |
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Rule out
used to indicate a differential diagnosis when one or more diagnoses are suspected |
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Plan
outline of the treatment plan designed to remedy the patients condition |
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