PATIENT:MRN / DOB:DATE / TIME:SOURCE:PCP:

CHIEF COMPLAINT:(age, pertinent PMH, chief complaint, duration)

HISTORY OF PRESENT ILLNESS:(present illness in chronological fashion, pertinent positives / negatives, relevant data)

PAST MEDICAL HISTORY:(chronological listing of surgeries and serious medical conditions, with dates and current status)

1.

(health maintenance, including PAP, mammogram, and colonoscopy)

MEDICATIONS:(admission medications, including doses; cross check any chart information with patient)

1.

ALLERGIES / ADVERSE REACTIONS:(include type of reaction)

1.

IMMUNIZATIONS:(include Pneumovax, influenza, Hep A, Hep B, and tetanus)

SOCIAL HISTORY: (current living situation [support at home, presence of threatening environment])

(occupation, interests)

(cultural background [origin, language, spiritual beliefs, complementary medicine, health literacy])

(habits [AODA, sexual behaviors, diet, exercise])

FAMILY HISTORY:(conditions related to patient)(common disorders [breast CA, colon CA, HTN, CAD, hypercholesterolemia, HH])

REVIEW OF SYSTEMS: (circle positives and elaborate, cross out negatives)

• general: fever, chills, night sweats, weight change, appetite

• skin: rashes, growing moles, non-healing lesions

• musculo: bone pain, joint pain, joint swelling, muscle aches, fracture Hx

• head: headache, dizziness

• eyes: last eye exam, change in vision, pain, double vision

• ears: pain, discharge, decreased hearing, tinnitus

• nose: bleeding, discharge, sinus pain

• oropharynx: sores, teeth, bleeding gums

• neck: pain

• nodes: enlargement, tenderness

• breasts: lumps, pain, galactorrhea

• respiratory: cough, wheezing, sputum, hemoptysis, SOB, pleuritic CP, snoring, daytime somnolence

• CV: SOB, orthopnea, PND, edema, chest discomfort, palpitations, syncope

• GI: dysphagia, heartburn, hematemesis, N/V/D/C, pain, swelling, melena, hematochezia, hemorrhoids, incontinence, jaundice

• GU: burning, pain, hematuria, frequency, hesitancy, dribbling, nocturia, incomplete emptying, incontinence, testicular masses, sexual function

• gynecologic: GxPx, LMP, excess / irregular / postmenopausal bleeding, dysmenorrhea, hot flashes

• neurologic: paralysis, weakness, paresthesia, transient loss of speech or vision, memory loss, vertigo

• psychiatric: anxiety, sadness, moodness, irritability

PHYSICAL EXAM:(pertinent positives and negatives; items with an * should be explained if not performed) (for vitals, be sure to include weight, BMI, SpO2, and whether pulse is regular or irregular)

• general:

• vital signs:

• skin:

• HEENT:

• neck:

• nodes:

• breasts*:

• chest:

• heart:

• abdomen:

• extremities:

• musculo:

• neurologic:

• genital*:

• rectal*:

LABORATORY:

IMAGING / OTHER PROCEDURES:

PROBLEM LIST:(list ALL problems identified via Hx, PE, testing; group problems, but only when diagnosis is certain)

1.

SUMMARY:(brief restatement of CC and pertinent history / findings, along with suspected diagnosis)

ASSESSMENT:(list of active problems and likely causes, ordered by relative importance in hospitalization)

1.

PLAN:(outline of what is being done for the patient)

1.

REFERENCES:(those read to learn about patient’s symptoms, diagnoses, diagnostic tests, and/or therapies)

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