GAUTHAM COLLEGE OF PHARMACY

This component is in a detailed, narrative format and describes the patients self-report of their current status in terms of their function, disability, symptoms and history. It may also include information from the family or caregivers and if exact phrasing is used, should be enclosed in quotation marks. It allows the therapist to document the patients perception of their condition as it relates to their progress in rehabilitation, functional performance or quality of life.

 

Initially is the patient's Chief Complaint, or CC. This is a very brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization.

 

If this is the first time a physician is seeing a patient, the physician will take a History of Present Illness, or HPI. This describes the patient's current condition in narrative form. The history or state of experienced symptoms are recorded in the patient's own words. All information pertaining to subjective information is communicated to the healthcare provider by the patient or his/her representative. It will include all pertinent and negative symptoms under review of body systems. Pertinent medical history, surgical history, family history, and social history, along with current medications, smoking status, drug/alcohol/caffeine use, level of physical activity and allergies, are also recorded. A SAMPLE history is one method of obtaining this information from a patient.

 

Subsequent visits for the same problem briefly summarize the History of Present Illness (HPI), including pertinent testing + results, referrals, treatments, outcomes and followups.

 

The mnemonic below refers to the information a physician should elicit before referring to the patient's "old charts" or "old carts."

Onset
Location
Duration
CHaracter (sharp, dull, etc.)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc.)
Severity

 

Variants on this mnemonic (more than one could be listed here) include OPQRST and LOCQSMAT

Location
Onset (when and mechanism of injury - if applicable)
Chronology (better or worse since onset, episodic, variable, constant, etc.)
Quality (sharp, dull, etc.)
Severity (usually a pain rating)
Modifying factors (what aggravates/reduces the symptoms - activities, postures, drugs, etc.)
Additional symptoms (un/related or significant symptoms to the chief complaint)
Treatment (has the patient seen another provider for this symptom?)

 

Common Errors

• Passing judgement on a patient e.g. "Patient is over-reacting again".

• Documenting irrelevant information e.g. patient complaining about previous therapist.