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 patients symptoms, diagnoses, diagnostic tests, and/or therapies)
Signature:

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