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15 Cards in this Set
- Front
- Back
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Informant
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source of information
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Chief Complaint (CC)
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reason for the visit
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History of Present Illness (HPI)
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onset, course, treatment for CC
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Medications
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list with doses/time of day, reason for medications, include OTC
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Allergies
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list and ask what happens
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Past Medical History (PMH)
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all hospitalizations; medical illness; trauma; OB/GYN hx; surgeries
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Family History
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blood relatives - review illnesses (i.e. HTM; DM; CA); age; ?deceased
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Social History
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place of birth; education; occupation; diet; exercise; caffiene intake; drug/ETOH use; tobacco use
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Review of Systems (ROS)
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list by symptoms; expand on postive symptoms
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Physical Exam (PE)
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complete from head to toe; includes neuro and mental status
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General Appearance
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describe patient’s appearance
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Vital Signs
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TPR; BP; weight; height
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Skin
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inspect color, lesions, moisture, edema
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Head
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includes face, scalp, neck
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Head - inspect
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general size & contour; facial expression; symmetry of neck; involuntary movements?; edema?; lesions?; active ROM;
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