Documentation Components

Front 1

HPI (History of Present Illness)

Back 1

Where you would document the history of the patient's chief complaint (explaining what brought them into the Emergency Department).

Front 2

Location

Back 2

The location of the chief complaint (i.e. left chest, lower abdomen, etc.)

Front 3

Severity

Back 3

The severity of the pain/chief complaint (i.e. mild, moderate, severe, 10/10)

Front 4

Timing

Back 4

The frequency of the chief complaint (i.e. constant, intermittent, waxing and waning)

Front 5

Quality

Back 5

The description of the chief complaint (i.e. sharp, burning, shooting, stabbing)

Front 6

Onset

Back 6

When the chief complaint began (i.e. 4 hours ago, 2 days ago, 20 minutes prior to arrival)

Front 7

Context

Back 7

Th circumstances surrounding the onset of the chief complaint (i.e. pain began while mowing lawn, vomiting began after eating an old burrito)

Front 8

Associated Symptoms

Back 8

Symptoms that are directly related to the chief complaint.

Front 9

Modifying Factors

Back 9

Anything that makes the chief complaint better or worse (i.e. pain is worse with walking)

Front 10

Past, Medical, Family, Social History (PMFSHx)

Back 10

Where you would document the patient's personal medical, surgical, family, and social history (previous conditions, etc.)

Front 11

Medical History

Back 11

This includes anything pertaining to the patient’s personal medical history (including pre-existing conditions or previous surgeries)

Front 12

Family History

Back 12

Contains the hereditary conditions of the patient’s immediate family members (parents, grandparents, siblings, etc.)

Front 13

Social History

Back 13

An age appropriate review of the patient’s past and current activities (i.e. tobacco use, employment, marital status, living status, drug use, alcohol use, homelessness, etc.)

Front 14

Review of Systems (ROS)

Back 14

Where you would document all of the patient's other subjective symptoms (both positive and negative) not related to the chief complaint.

Front 15

Physical Examination (PE)

Back 15

The objective process by which a doctor investigates a patient's body for signs of disease. (This is from the doctor's point of view)

Front 16

ED Course

Back 16

A chronological timeline of what occurred during a patient’s stay in the ED

Front 17

EKG/ECG (Electrocardiogram)

Back 17

A test that checks for problems with the electrical activity of the heart.

Front 18

Procedures

Back 18

Actions performed by the physician during a patient's stay in the Emergency Department (i.e. repairing a cut etc.)

Front 19

Orders

Back 19

Directions given by the doctor to perform tests or administer treatment/medications.

Front 20

Radiology

Back 20

The use of imaging to both diagnose and treat disease visualised within the human body. (i.e. x-rays, MRIs, CTs, etc.)

Front 21

Labs

Back 21

Tests performed on body fluids and excretions (i.e. blood, urine, stool, etc.) in order to get information about the health of a patient.

Front 22

Prescription

Back 22

A written document given to a patient authorizing a medicine or treatment.

Front 23

Vital Signs

Back 23

Signs that may be watched, measured, and monitored to check an individual's level of physical functioning. (i.e. temperature, blood pressure, pulse oximetry, respiratory rate, heart rate/pulse)

Front 24

Disposition

Back 24

The plan for action after the patient leaves the Emergency Department (i.e. admitted to the hospital, discharged home, etc.)

Front 25

Diagnosis

Back 25

What the doctor has determined to be the cause of the patient's chief complaint/symptoms.

Front 26

Condition

Back 26

The current condition of the patient upon re-evaluation and/or discharge (i.e. improved, expired, worsened, unchanged)

Front 27

Caveat

Back 27

An acceptable reason as to why the physician is unable to obtain a patient's complete history (i.e. obtunded, altered mental status, seizure, etc.)