Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Admitting Physician:
Admitting Service:
Chief Complaint (CC)
Briefly state the patient’s primary reason for admission in their own words if possible.
Include the duration of the complaint.
History of Present Illness (HPI)
Onset: When did the symptoms begin?
Progression: How have the symptoms changed over time?
Aggravating/Alleviating Factors: What makes the symptoms worse or better?
Associated Symptoms: List any other relevant symptoms the patient is experiencing.
Treatment History: Mention any medications or treatments the patient has tried for the current condition.
Past Medical History (PMH)
List any significant medical conditions the patient has been diagnosed with.
Include relevant surgeries and hospitalizations.
Mention any allergies the patient has.
Past Surgical History (PSH)
Briefly list any prior surgical procedures.
Medications (Meds)
List all medications the patient is currently taking, including:
Medication name
Dosage
Frequency
Route of administration (e.g., oral, intravenous)
Social History (SH)
Briefly discuss the patient’s lifestyle habits, such as smoking, alcohol use, and occupational hazards.
Mention the patient’s living situation and social support system.
Family History (FH)
Briefly note any relevant medical conditions that run in the patient’s family.
Review of Systems (ROS)
Conduct a systematic review of all body systems by asking the patient about any abnormal symptoms they may be experiencing.
Document pertinent positive and negative findings.
Physical Examination (PE)
Vital Signs: Record blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.
General: Describe the patient’s overall appearance, including body habitus and distress level.
HEENT (Head, Eyes, Ears, Nose, Throat): Document any abnormalities in these areas.
Neck: Assess lymph node enlargement, tenderness, or range of motion.
Cardiovascular: Evaluate heart sounds, rhythm, and presence of murmurs.
Respiratory: Assess breath sounds, chest wall expansion, and use of accessory muscles.
Abdomen: Evaluate for distention, tenderness, masses, and organomegaly.
Neurological: Assess mental status, cranial nerves, motor function, and sensory function.
Musculoskeletal: Evaluate muscle strength, joint integrity, and range of motion.
Skin: Describe skin texture, color, and presence of lesions.
Assessment and Plan
Summarize the patient’s current condition, including key findings from the history and physical examination.
Formulate a working diagnosis or a differential diagnosis.
Outline the initial treatment plan, including medications, investigations, and procedures.
Identify any potential social or emotional concerns that may impact care.