The Clinical Record

Putting the History and Physical Examination Together

Until this point, this book has dealt separately with the history and the physical examination. Chapter 1, Chapter 2, Chapter 3, Chapter 4, Chapter 5 give an in-depth analysis of history-taking techniques. Chapter 6, Chapter 7, Chapter 8, Chapter 9, Chapter 10, Chapter 11, Chapter 12, Chapter 13, Chapter 14, Chapter 15, Chapter 16, Chapter 17, Chapter 18, Chapter 19, Chapter 20, Chapter 21 discuss the many elements of the physical examination, and Chapter 22 suggests an approach to performing the complete physical examination and its write-up. Chapter 23, Chapter 24, Chapter 25, Chapter 26 cover the evaluation of specific patients. Chapter 27 discusses data gathering, data analysis, and critical thinking. This chapter suggests how the history and the physical examination can be integrated into one comprehensive statement about the patient.

In writing up the history and the physical examination, the examiner should follow several rules:

• Record all pertinent data.

• Avoid extraneous data.

• Use common terms.

• Avoid nonstandard abbreviations.

• Be objective.

• Use diagrams when indicated.

The patient's medical record is a legal document. Comments regarding the patient's behavior and attitudes should not be part of the record unless they are important from a medical or scientific standpoint. Describe all parts of the examination that you performed and indicate those that you did not perform. A statement such as “the examination of the eye is normal” is much less accurate than “the fundus is normal.” In the first case, it is not clear whether the examiner actually attempted to look at the fundus. If a part of the examination was not performed, state that it was “deferred” for whatever reason. Finally, it is not necessary to state all the possible abnormalities if they are not present. It is acceptable to state that “the pharynx was normal” instead of “the pharynx was not injected, and there was no evidence of discharge, erosion, masses, or other lesions.” It is clear from the first statement that the examiner inspected the pharynx and believed that it was normal.

Now consider again the patient Mr. John Doe, whose interview was recorded in Chapter 4 , Putting the History Together. The following text describes the complete history and physical examination of this patient.