PATIENT CHART
SOCIAL HISTORY
- a collection of documents that provides an account
of each episode in which a patient visited or sought
treatment and received care or a referral for care
from a health care facility.
- The record is confidential and is usually held by the
facility, and the information in it is released only to
the patient or with the patient's written permission.
It contains the initial assessment of the patient's
health status, the health history, laboratory and
radiologic reports of tests performed, notes by
nurses and physicians regarding the daily condition
of the patient, and notes by consultants, as well as
order sheets, medication sheets, admission records,
discharge summaries, and other pertinent data.
- A problem-oriented medical record also contains a
master problem list.
- The patient record is often a collection of papers
held in a folder, but it may be computerized.
INFORMATION IN PATIENT CHART
1. PATIENT DEMOGRAPHICS
- a narrative or record of past events and
circumstances that are or may be relevant to a
patient's current state of health. Informally, an
account of past diseases, injuries, treatments, and
other strictly medical facts.
- More formally, a comprehensive statement of facts
pertaining to past and present health gathered,
ideally from the patient, by directed questioning and
organized under the following heads.
- Patient Name, Age, Gender, Status, Address,
Occupation, Religion
2. CHIEF COMPLAINT (CC)
- a brief statement of the complaint or incident that
prompted medical consultation.
- Indicate the reason of admission to the hospital in
the words of the informant.
- Example:
“I’m having pain in my leg.”
“I was not feeling well, and I think I passed out.”
“My right arm feels like it’s frozen. I can barely move
it.”
3. HISTORY OF PRESENT ILLNESS (HPI)
- a detailed chronologic narrative, as much as possible
in the patient's own words, of the development of
the current health problem from its onset to the
present.
- A chronologic description of the development of the
Pt's present illness
4. PAST MEDICAL HISTORY
- prior illnesses, their treatments and sequelae
5. FAMILY HISTORY
- present health or cause of death of parents,
brothers, sisters, with particular attention to
hereditary disorders
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6.
- marital status, past and present occupations, travel,
hobbies, stresses, diet, habits, and use of tobacco,
alcohol, or drugs.
7. MEDICATIONS, ALLERGIES, IMMUNIZATIONS
- List any medications prescription, including over-the-
counter medications, home remedies, vitamins, and
supplements as well.
8. REVIEW OF SYSTEMS (ROS)
- an exhaustive survey of symptoms or diseases,
organized by body system, not covered in previous
parts of the history.
- a system-by-system review of the body
functions. organized and complete examination of a
Pt's organ systems as part of the workup when the
Pt is first seen by a physician; an ROS is an inventory
of body systems obtained by verbal history, with the
signs and/or Sx which the Pt is experiencing or had
- Example: “Do you have any problems breathing?”
“Do you have shortness of breath when exercising,
walking, climbing the stairs?”
Skin: bruising, discoloration, pruritus, birthmarks, moles,
ulcers, changes in the hair or nails, sun exposure and
protection.
Ears: tinnitus, change in hearing, running or discharge from
the ears, deafness, dizziness.
Eyes :change in vision, pain, inflammation, infections, double
vision, scotomata, blurring, tearing.
Mouth and throat :dental problems, hoarseness, dysphagia,
bleeding gums, sore throat, ulcers or sores in the mouth.
Nose and sinuses discharge, epistaxis, sinus pain, obstruction.
Breasts pain, change in contour or skin color, lumps,
discharge from the nipple.
9. THE PHYSICAL EXAMINATION
- Evaluation of the body and its functions using
inspection, palpation , percussion , and auscultation .
- Comprehensive physical examinations provide
opportunities for health care professionals to obtain
baseline information about individuals that may be
useful in the future. They also allow health care
providers to establish relationships before problems
occur.
10. LABORATORY TEST
- A generic term for any test regarded as having value
in assessing health or disease states.
11. THE PROBLEM LIST
- any health care condition that requires diagnostic,
therapeutic, or educational action
12. THE PLAN
What is the difference between ROS and Physical Exam?
- The ROS are written or verbal “questions and
answers” relevant to signs or symptoms the patient
is experiencing at the time of service. Often, the ROS
 is gathered by having the patient complete a history
or intake form given to the patient at the front desk
check-in. The form includes a list of questions, on
which the patient “checks off” and briefly explains
his or her signs and symptoms.

- The ROS may also occur verbally with the provider or

other staff. For instance, an assistant may ask the
patient, “Do you have any problems breathing? Do
you have shortness of breath when exercising,
walking, climbing the stairs?” If ancillary staff
documents the ROS, the provider must review the
information to use it for E/M selection.

- The provider might document the patient’s response

in a note as briefly as, ”Patient states his chest hurts
when he coughs, but not when he takes a deep
breath. No SOB. No complaints of pain in joints. No
problems sleeping.”

- If the provider uses a subjective, objective,

assessment, and plan (SOAP) documentation format,
the ROS elements should appear under the heading
“Subjective.”

- In contrast to the elements of the ROS, the elements

of an exam are actual visual or “hands-on” findings.
For example, the provider uses an otoscope to
inspect the middle ear visually, an ophthalmoscope
to check the eyes and their reaction to light, and a
stethoscope to listen to lung, heart, and bowel
sounds.
- The bottom line: When reading the notes, decide if
the notation is something the patient answered, or if
it is something the provider observed. A question
that is answered belongs to the ROS, whereas
something the provider sees, hears, or
measures upon examination is an element of the
exam.

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