The Health Record - Clinical Tree

After performing the history and physical examination, the healthcare clinician must organize, synthesize, and record the data along with the problems identified and the rationale for the diagnostic evaluation and plan of care. This cognitive effort goes well beyond simply transcribing or importing data that may exist from other sources or completing prescribed templates. The information in the patient’s health record must enable you and your colleagues to know and care for the patient by identifying health problems, making diagnoses and judgments regarding the diagnostic testing needed, planning appropriate care, and monitoring the patient’s responses to treatment. The patient’s health record is only as good as the accuracy, pertinent depth and detail, and thoughtful synthesis provided by the documenting caregivers. With the transition to the electronic health record (EHR), it is even more critical to maintain standards of documentation excellence. Within the EHR environment, there is great risk in overwhelming the reader with volumes of insignificant or inaccurate data through importing preexisting and unverified information from other sources within the record. This phenomenon, sometimes referred to as “note bloat,” must be guarded against.

Multiple beneficial functions can now be achieved with the EHR beyond documentation and communication among the team of the patient’s caregivers and with the patient directly through patient portals. These functions include, among others: order entry, risk stratification, population health reporting, provision of care pathways, and the exchange of health information among different healthcare systems.

The patient’s health record is a legal document. Any information contained in it may be used in court and in other legal proceedings as well as to determine healthcare payment. Your documentation will be read by many individuals; increasingly, and appropriately, this includes the patient and their family members. It is your responsibility to document the facts of the history and your physical examination findings accurately.

General Guidelines

It is quite acceptable to take brief written or typed notes regarding the patient’s concerns and history along with your findings during the course of the interview and physical examination. It is important and respectful to request permission and inform the patient you will be taking these notes during the visit. It is not necessary to record all the details during the visit as this may distract your attention from the patient. Documenting simple notes should be sufficient in preparation for the subsequent complete note. This allows you to gather, reflect, and organize all the data appropriately before making the record final. Certain data should be recorded as you obtain it, specifically the vital signs and any measurements. It is essential to complete the essence of the patient’s story and key findings as soon as possible after the examination while your memory for detail is fresh. Resist going on to other patients before doing so. Although this is sometimes unavoidable, you can easily become confused about which patient had a particular finding and even forget to record an important finding.

In the EHR all entries will be dated and timed when signed and cannot be subsequently erased. If using a paper chart, recorded information should not be erased. Instead, make necessary changes by lining out data and leaving this crossed-out information legible while initialing and dating the changes. When using an EHR, include an addendum to correct or update your documentation. Any portion of the examination that has been deferred or omitted should be so noted, rather than neglecting to mention particular findings. It is appropriate in some circumstances to defer a portion of an examination, stating the reason for deferral. For example, if doing a visit through video transmission, your ability to do a complete examination will be limited. A clear and exact record of your assessment, an analysis of the problem, and your rationale for the management plan are vital for communicating with other healthcare providers and for your protection in case there is ever a question raised relevant to your care of the patient.

It is unacceptable to copy other healthcare providers’ documented work (e.g., history taken, examination performed, or thought processes outlined) and enter it into your own documentation as if you did the work. Text copied from another person’s note must always be attributed to the source. Information integrity refers to the dependability of information and is further defined as the accuracy, consistency, and reliability of information content. This is not only an important concept in a legal proceeding; it is critical for safe patient care. Hospital care is often fragmented, and handoffs and cross-coverage prevail. Healthcare providers need to be able to trust the documentation on which they will base clinical decisions at the point of care.

Be concise, yet avoid the use of abbreviations and symbols as much as possible as meanings may differ among health professionals ( Box 5.1 and Table 5.1 ) (Garbutt et al., 2008). Similarly, avoid the use of words such as “normal,” “good,” “poor,” and “negative” because these words are open to various interpretations by other examiners.

Box 5.1

Abbreviations and Acronyms: The Initial Challenge to Reliability

There was a time when recorded histories and physical examinations contained few, if any, acronyms. After World War II, the use of initials began to proliferate. Today it is a compulsive problem leading to misunderstanding that is at times inconvenient and at times dangerous.

When our interprofessional languages are obscured by acronyms, communication suffers and the safety of patients may be compromised. For example, ROM has many meanings. The obstetrician uses ROM for “rupture of membranes.” The pediatrician uses ROM for “right otitis media.” The physiatrist uses ROM for “range of motion.” The following statement taken from a hospital chart demonstrates how abbreviations can cause confusion (Abushaiqa et al., 2007):

67yo CM who CVA, CABG×2, GERD, CRI on HD, POD #5 - Ex Lap for MVC with OA, s for WO & RFCOAW.

TABLE 5.1

Prohibited Abbreviations

The Joint Commission has identified “improving communications among caregivers” as a patient safety goal (Joint Commission, 2020). Certain abbreviations have been placed on a “do not use” list when an error in misreading the abbreviation could cause harm.
When considering the use of initials, abbreviations, and acronyms to work quickly, resist the temptation.
OFFICIAL “DO NOT USE” LIST ^a
Do not use	Potential problem	Use instead
U (unit)	Mistaken for “0” (zero), the number “4” (four) or “cc”	Write “unit”
IU (International Unit)	Mistaken for IV (intravenous) or the number 10 (ten)	Write “International Unit”
Q.D., QD, q.d., qd (daily)	Mistaken for each other	Write “daily”
Q.O.D., QOD, q.o.d., qod (every other day)	Period after the Q mistaken for “I” and the “O” mistaken for “I”	Write “every other day”
Trailing zero (X.0 mg) ^b	Decimal point is missed	Write X mg
Lack of leading zero (.X mg)		Write 0.X mg
MS	Can mean morphine sulfate or magnesium sulfate	Write “morphine sulfate”
MSO ₄ and MgSO ₄	Confused for one another	Write “magnesium sulfate”

From The Joint Commission. Reprinted with permission.

a Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.

b Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

Document what you observe and what the patient tells you, rather than the conclusions you interpret or infer. Use direct quotes from the patient when a description is particularly vivid, especially when documenting the patient’s chief concern. This is an effective way to capture the patient’s perspective of their health situation. Keep subjective and symptomatic data in the history, making sure these aspects are not woven into the physical findings. Physical examination findings should be the result of your direct observation. For example, when a patient reports pain (a symptom) during palpation, you should note tenderness (a sign) in the record and report the patient’s reaction to pain, such as crying, withdrawal, rigid posturing, or facial expression. Record both what the patient tells you and what you observe. Detectable changes can then be better compared and documented in the future. Clues about health changes and trends over time are lost if such details are not recorded in the patient’s record.

EHR Functions

Multiple functions can now be achieved within the EHR, well beyond the documentation and communication purposes that were achieved through traditional paper-based charting. These activities include, among others, order entry, risk stratification, population health reporting, provision of care pathways, as well as the exchange of health information among different healthcare systems and direct communication between patients and their healthcare teams through patient portals. By combining the clinical and administrative data that exists within a single EHR and among other data sources, additional benefit can be attained to enhance patient care.

Order Entry

Computerized Provider Order Entry (CPOE) has been a major emphasis in achieving meaningful use of the EHR. By using CPOE for medications and laboratory and radiology studies, a health system can reduce errors and enhance patient safety through several mechanisms. These orders are legible and congruent with the standardized inventory of pharmaceutical therapies and diagnostic studies performed. Clinical decision algorithms can be applied to alert the clinician to such risk s as medication allergies, drug interactions, and dosage inaccuracies.

Risk Stratification

Risk stratification can facilitate clinicians in assigning risk s of specific clinical outcomes to subgroups of patients. By using data that exists within the EHR, this information can then be used to direct specific interventions to those patient cohorts that carry the highest risk . While a specific risk score may be generated by the particular algorithm, it is generally translated into a “low,” “medium,” or “high” risk category. This allows high-intensity interventions to be focused on patients who carry the greatest risk of developing an adverse outcome with the aim of achieving a greater benefit. Examples of such stratification algorithms include the evaluation of the risk of a cardiac event as a result of non-cardiac surgery or the risk of progression of a patient’s prostate cancer.

Population Health Reporting

Population health is a term used to signify the synergistic activity of various organizations to improve the health outcomes of the communities that they serve. Such participating organizations within a community can be drawn from local businesses, health systems, government agencies, service organizations or public policy entities. This represents the intersection of clinical outcomes, determinants of health and public policy. By leveraging the capacity of the EHR to analyze and report clinical and demographic data regarding the community health status, population health interventions can be designed and implemented. One such example is through the analysis of gaps in care within a specific population . This can lead to targeted interventions to enhance community wellness and prevention programs.

Care Pathways

Care pathways, also referred to as critical or clinical pathways, are standardized evidenced-based healthcare plans and processes designed for patients within a specific clinical setting to enhance their care (Hipp et al., 2016). By drawing upon each member of the interprofessional team caring for the patient, the designed pathway reduces the unnecessary variation in care to achieve improved patient outcomes. Through incorporating these established pathways into the EHR, each member of an interdisciplinary team can clearly understand the team goals for the care of the patient and the specific role of each team member in achieving those goals. One area where this has been found to be successful is with the enhanced recovery of patients after surgery.

Health Information Exchange

Electronic health information exchange ( HIE ) allows clinicians and patients and, when designated, their family members to secure access to pertinent and appropriate portions of the patient’s health record. By facilitating the timely sharing of vital health information that has been generated across multiple health systems, clinicians can potentially avoid duplicate testing, unnecessary admissions, medication errors, and can improve diagnostic and therapeutic plans.

Replication

Although potentially an effective tool, the ability to easily copy and paste or carry forward text from one note to another has become the latest hazard in medical documentation and presents as a patient safety, legal, and regulatory challenge ( Box 5.2 ). When used inappropriately, it can render meaningless an essential communication tool relied on at the point of care ( Box 5.3 ). All copied information must be verified and subsequently edited or removed as necessary to ensure that it is not erroneous or out of date. Text copied from another healthcare professional’s note must always be attributed to the source.

Box 5.2

Use and Misuse of CPCF

CPCF , Copy and paste or carry forward.

Although text replication is generally discouraged, it can improve efficiency, decrease information drop-off, and decrease typing errors; therefore, some uses are potentially acceptable.

Potentially Acceptable Uses of CPCF

1.
The author’s previously documented assessment and plan on a given patient that has carried forward to subsequent notes, subject to editing for relevance and accuracy
2.
Auto populated, presumably static information (e.g., past medical history and family history) entered by other healthcare providers and carried forward into new documents, subject to confirmation and editing if needed
3.
Cumulative, dated information that carries forward to create a running log of daily hospital events
4.
Copying and pasting important lists or information (e.g., medication lists), which can prevent potential clinically relevant retyping errors

Unacceptable Uses of CPCF

1.
Copying previous healthcare providers’ documented work (e.g., history, examination, or thought processes) and entering it into a new note unedited (or minimally edited) as if the new author did the work
2.
Unedited text carried forward from other notes (including the author’s) that results in conflicting or inaccurate information
3.
Unedited or minimally edited notes carried forward from day to day that do not allow readers to determine changes in clinical course

Box 5.3

Implications of Misuse of CPCF

CPCF, Copy and paste or carry forward.

1.
Copying subjective information obtained by other healthcare providers without appropriate editing degrades patient narratives, which form the basis for complex decision making.
2.
Perpetuation of inaccurate data or diagnoses cloned from previous notes can result in poor patient care decisions.
3.
Incorporating (or not removing) redundant or irrelevant information lengthens the document, dwarfs the information that is most important at the time, and makes it difficult to determine what is old and new. When urgent information is needed at the point of care, patient safety can suffer.
4.
Unless edited and reorganized daily, copied assessments and plans may not reflect changes in a patient’s status or clinical course (e.g., “pulmonary” is always on top though may not be currently relevant); in handwritten notes, healthcare providers usually filter and organize pieces of information that are most relevant to the patient’s care at the time.
5.
When healthcare providers authenticate their notes containing large amounts of text from previous healthcare providers, it can appear as though they did not do the work (e.g., take the history, formulate the plan) themselves. Taking credit for parts of a note that one did not create is not only unethical, it can result in mistrust of the entire document by the legal system and be considered fraud by payers and regulators such as The Joint Commission.
6.
When copied text is not edited appropriately, conflicting information or improper time representation can call into question the reliability of the entire note.

Organization of the Note

Most healthcare providers use a customary organization of information from the interview and physical examination. Healthcare facilities often incorporate the information in standardized forms or templates within the health record. Following this customary outline of information enables all healthcare providers in an integrated system to find and use the patient information more efficiently. The problem-oriented health record (POHR) with SOAP ( S ubjective, O bjective, A ssessment, and P lan) notes is one such system. The POHR can also be created in the APSO ( A ssessment, P lan, S ubjective, and O bjective) format.

Organizing the Patient’s Health Record with SOAP Notes

S Subjective data—the information, including the absence or presence of pertinent symptoms, that the patient tells you
O Objective data—your direct observations from what you see, hear, smell, and touch and from diagnostic test results
A Assessment—your interpretations and conclusions, your rationale, the diagnostic possibilities, and present and anticipated problems
P Plan—diagnostic testing, therapeutic modalities, need for consultants, and rationale for these decisions

Subjective Data

Subjective data are the information that patients offer about their condition.

Describe the patient’s concerns or unexpected findings by their quality or character. For example, indicating the presence of pain without providing characteristics (e.g., timing, location, severity, and quality) is not useful either for determining the extent of the present problem or for future comparison. Record the severity of pain using the patient’s response or score on a pain scale. Be sure to name the pain scale in the record. The severity of pain may also be described by its interference with activity or disruption of sleep. Note whether the patient is able to continue regular activity despite pain, or whether it is necessary to decrease or stop all activity until pain subsides (see Chapter 6 ). Similar detail should be provided for other signs.

Objective Data

Objective data are the findings resulting from direct observation—what you see, hear, and touch.

Relate physical findings to the processes of inspection, palpation, auscultation, and percussion, making clear the process of detection so confusion does not occur. For example, “no masses on palpation” may be stated when recording abdominal findings. Include details about expected objective findings, such as “tympanic membranes pearly gray, translucent, light reflex and bony landmarks present, mobility to positive and negative pressure bilaterally.” Also, provide an accurate description of unexpected objective findings. Suggestions for recording the character and quality of objective findings follow.

Location of Findings

Use topographic and anatomic landmarks to add precision to your description of findings. Indicating the liver span measurement at the midclavicular line enables future comparison because measurement at this location can be replicated. The location of the apical impulse is commonly described by both a topographic landmark (the midsternal line) and an anatomic landmark (a specific intercostal space), for example, “the apical impulse is 4 cm from the midsternal line at the fifth intercostal space.”

In some cases, location of a finding on or near a specific structure (e.g., tympanic membrane, rectum, vaginal vestibule) may be described by its position on a clock. It is important that others recognize the same landmarks for the 12 o’clock reference point. For rectal findings, use the anterior midline, and for vaginal vestibule findings (e.g., Bartholin glands, episiotomy scar), use the clitoris.

Incremental Grading

Findings that vary by degrees are customarily graded or recorded in an incremental scale format. Pulse amplitude, heart murmur intensity, muscle strength, and deep tendon reflexes are findings often recorded in this manner. In addition, retinal vessel changes and prostate size are sometimes graded similarly. See the chapters in which these examination techniques are discussed for the grading system used to describe the findings.

Organs, Masses, and Lesions

For organs, any type of mass (e.g., an enlarged lymph node), or skin lesion, describe the following characteristics noted during inspection and palpation:

Texture or consistency: smooth, soft, firm, nodular, granular, fibrous, matted
Size: recorded in centimeters on two dimensions, plus height if the lesion is elevated. Future changes in the lesion size can then be accurately detected. (This is more precise than comparing the lesion’s size to fruit or nuts, which have different dimensions.)
Shape or configuration: annular, linear, tubular, elliptical
Mobility: moves freely under skin or fixed to overlying skin or underlying tissue
Tenderness
Induration
Heat
Color: hyperpigmentation or hypopigmentation, redness or erythema, or the specific color of the lesion
Location
Other characteristics, for example, oozing, bleeding, discharge, scab formation, scarring, excoriation

Discharge

Regardless of the site, describe discharge by color and consistency (e.g., clear, serous, mucoid, white, green, yellow, purulent, bloody, or sanguineous), odor, and amount (e.g., minimal, moderate, copious).

Illustrations and Photographs

Illustrations and photographs can sometimes provide a better description than words and should be used when appropriate. Illustrations with labeling are particularly useful in describing the origin of pain, where it radiates, and the size, shape, and location of a lesion ( Fig. 5.1 ). Photographs included in the EHR can provide useful information, although you need to be aware of any institutional consent policies that apply to this practice.

FIG. 5.1, Illustration of the location of a breast mass.

Problem-Oriented Health Record

The POHR is a commonly used process to organize patient data gained during the history and physical examination. After the history and physical examination are completed, the POHR provides a format for collecting and recording your thoughts that assists with critical thinking and clinical decision making—determining the patient’s problems as well as the possible and probable diagnoses.

After the subjective and objective data are documented, along with the problems identified, the diagnostic and therapeutic plan is made with the patient as a full participant. The health record describes plans made and rationale for actions taken to address these problems, lists the information and education provided to the patient, and describes the patient’s response to care provided.

The record must be well organized, precise, and concise to facilitate your thinking and the thinking of your colleagues who may need to care for the patient. The consistent recording format enables more effective communication and coordination among professionals caring for the patient.

There are six components of the POHR:

1.
Comprehensive health history
2.
Complete physical examination
3.
Problem list
4.
Assessment and plan
5.
Baseline and problem-directed laboratory and radiologic imaging studies
6.
Progress notes

Comprehensive Health History and Complete Physical Examination

All relevant data regarding the comprehensive health history should be recorded, including both absence and presence of pertinent findings that contribute directly to your assessment. Arrange the history in chronologic order, starting with the current episode and then filling in relevant background information. Arrange the physical examination findings in a consistent order and style. This allows future readers, and you, to find specific points of information. It also enables you to quickly remember key components for assessment on each encounter.

Make your headings clear, using indentations and spacing to accentuate the organization of your documentation. Be concise yet complete! Avoid abbreviations as much as possible.

Problem List

The problem list is created after the subjective and objective information has been organized. All pertinent data and examination findings, illustrations or pictures, laboratory data, imaging studies, and prior diagnoses are reviewed to develop a problem list in the form of a running log with the following information: problem number, date of onset, description of problem, and date problem was resolved or became an inactive concern.

A problem may be defined as anything that will require further evaluation or attention. Problems arise in many varieties, for example, the questions regarding diagnosis, the availability of diagnostic and therapeutic resources, ethical issues, and factors in the patient’s life—social, emotional, financial, work related, school related, family related, and even the availability of caretakers. A problem may be related to any of the following:

A firmly established diagnosis (e.g., diabetes mellitus, hypertension)
A new symptom or physical finding of unknown etiology or significance (e.g., right knee effusion)
New findings revealed by laboratory tests (e.g., microcytic anemia)
Personal or social difficulties (e.g., unemployment, homelessness)
Risk factors for serious conditions (e.g., smoking, family history of coronary artery disease)
Factors crucial to remember long term (e.g., allergy to penicillin)

You may describe problems in separate lists (e.g., diagnostic issues, care and therapeutic issues, and long-range issues) or you may make one list. The needs of a particular patient and the resources available to you will influence your judgment and your ultimate approach. The nature of the patient’s problems determines the sequence in which you list them. Problems may be listed in chronologic order or listed according to the problem severity. Some controlling variables with regard to the sequencing of listed problems include the following:

Possibility that the diagnosis is life-threatening and needs immediate attention; the relative gravity of the problem
Probability/possibility ratio: priority given to the probable diagnoses or therapeutic actions
Likelihood of the probabilities in a differential diagnosis—the more probable taking precedence
Availability and cost of the diagnostic, therapeutic, and caretaking resources; cost relative to need and availability
Time sequence in which the problems arose and the time sequence dictated by their relative urgency

This list enables all healthcare providers to quickly assess the patient’s history by the summary presented on this list. When a problem is resolved, the date of resolution should be entered, and this item can then be removed from the active problem list. Surgical correction of a condition and recovery from an acute infectious process are examples of resolved problems.

Assessment

The assessment section is composed of your interpretations and conclusions, their rationale, the diagnostic strategy, present and anticipated problems, and the needs of ongoing as well as future care—what you think (see Chapter 4 ).

Develop an assessment for each problem on the problem list. Begin the process of making a differential diagnosis by discussing and giving priority to possible causes and contributing factors for a problem or symptom. Present the rationale for the potential causes and validate the assessment from data contained in the comprehensive health history, physical examination, consultations, and any laboratory data available. When a serious potential cause is no longer under consideration, explain why.

Describe any pertinent absence of information when other portions of the history or physical examination suggest that an abnormality might exist or develop in an area (e.g., absence of wheezing in someone with dyspnea). Avoid the use of words such as “normal” or phrases such as “within normal limits,” or worse yet “WNL,” because they do not describe what is inspected, palpated, percussed, or auscultated. Be as objective as possible. Assessment may include anticipated potential problems such as complications or progression of the disease.

Plan

The plan describes the need to invoke diagnostic resources, therapeutic modalities, other professional resources, and the rationale for these decisions—what you intend to do.

Develop a plan for each problem on the problem list. The plan can be divided into three sections: diagnostics, therapeutics (if known), and patient education:

Diagnostics. List the diagnostic tests and consultations to be performed or ordered.
Therapeutics. Describe the therapeutic treatment plan. Provide a rationale for any change or addition to an established treatment plan. List any referrals initiated with their purpose and to whom the referral is made. State the target date for reevaluating the plan.
Patient education. Describe health education provided or planned. This should address the role of new therapies initiated and plans for patient requirements upon discharge. Include materials dispensed and evidence of the patient’s understanding or lack thereof.

SOAP Notes

The organization of the patient data within the POHR, especially for care beyond the initial evaluation, is often recorded in a series of SOAP notes. Each problem is recorded separately. Subjective and objective data relevant to each problem are clustered together, followed by the assessment and the plan ( Box 5.4 ). Alternatively, all of the subjective and objective data can be recorded in totality. Then the list of problems with the assessment and plan for each are written.

Box 5.4

Governing Principles for Using POHR, APSO, and SOAP

Record legibly the information you judge is needed; you will write more early in your career, but as time goes by, you will learn to edit with experience and wisdom, especially under the time pressures you will face.
Organize! Tell the unique story of your patient chronologically and precisely, including positive as well as relevant negative information.
Use clear headings.
Precision requires exact description; for example, use a tape measure to measure the size of swelling.
Be terse. An “erythematous” throat may also be described as “red,” and a bulge in an “eardrum” is as well understood as “tympanic membrane.”

APSO Notes

With widespread use of the EHR, one consequence that has occurred is an increased amount of data that can be incorporated in the note. While we should be ever vigilant against inappropriate “note bloat,” the busy healthcare provider may be challenged to quickly find the most clinically useful information: the assessment and plan. In the SOAP format one may be required to scroll or click through multiple screens before locating this. With the APSO format, the assessment and plan are moved to the beginning of the document, with all remaining data available in the remainder of the note.

Notes From Subsequent Evaluations

Whether it is during each of the hospital days after an inpatient admission (progress notes) or subsequent outpatient visits for episodic illness or preventative care (ambulatory care notes), the encounter is recorded within the health record. Because there exists in the record an established amount of baseline information, recording of the POHR can be focused primarily on updating information.

An interval history—including subjective status of the problem, current medications, and review of systems related to the problem—is presented in the subjective portion of the note. Medication reconciliation is a critical part of every visit in order to prevent adverse drug events. This is the process of determining an accurate list of all of the medications being taken by the patient. This includes the medication name along with the dosage, route, frequency, and any special instructions. It is not uncommon, especially when the patient is seeing multiple clinicians or has recently been hospitalized, that this list requires correction. The objective portion includes vital signs, a record of any physical examination performed at the time of the visit, and results of laboratory data or radiographic studies performed since the last visit.

The assessment section includes your evaluation of the problem status. If the problem was formerly a symptom, such as shortness of breath, you may have enough data to make a diagnosis. The rationale for the diagnosis is presented in this section, and the problems, allergies, and medications list is updated accordingly.

Similar to the comprehensive health history and examination documentation, plans are presented in three components: diagnostic, therapeutic, and patient education.

Problem-Oriented Health Record Format

The History

The patient’s history, especially for an initial visit, provides a comprehensive database. The following organized sequence will guide you in creating a POHR.

Identifying Information

The patient’s name, date of birth, and an assigned health record number are the first items of information recorded. Most health agencies have forms or EHR templates with headings for each category of information to be recorded. This information should be contained on every page of documentation.

Problems, Allergies, Medications, and Immunizations List

Although the problems, allergies, medications, and immunizations (PAMI) list itself is added to the record after the subjective and objective information has been organized, the POHR form can be reviewed at a glance by medical personnel. The PAMI list is an ongoing record of a patient’s medical problems, allergies with associated reactions, medications with dosages and instructions of how these are administered, and past immunizations. This list should be reviewed, reconciled, and updated with the patient at each visit and when admitted to the hospital.

For each entry, the date of onset or initiation is recorded along with the date that the problem was resolved, the medication discontinued, or the date and route that an immunization was given.

General Patient Information

Additional identifying information for each patient includes address, home and/or cell phone number, employer, work address and telephone number, e-mail address, marital status, health insurance status, and plan name with the member identification number. Often this information now includes the patient’s primary language, need for an interpreter, and preferred method of contact (phone, e-mail, patient portal).

Source and Reliability of Information

Document the historian’s identity—that is, the patient or the person’s relationship to the patient. State your judgment about the reliability of the historian’s information. Indicate when the history is taken from the patient’s health record.

Chief Concern/Presenting Problem/Reason for Seeking Care

The chief concern or presenting problem is a brief description of the patient’s main reason for seeking care. The information may be stated verbatim in quotation marks. Always include the duration of the chief concern or problem.

History of Present Illness

This section contains a detailed description of all symptoms that may be related to the chief concern, and it describes the concern or problem chronologically, dating events and symptoms. When describing the present illness, it is important for the examiner to record the absence of certain symptoms commonly associated with the particular area, or system, involved. Also inquire about anyone in the household with the same symptoms or possible exposure to infectious or toxic agents. If pertinent to the present illness, include relevant information from the review of systems, family history, and personal/social history. When more than one problem is identified, address each problem in a separate paragraph. Include the following details of each symptom’s occurrence, described in narrative form by categories:

Onset: when the problem or symptom first started; chronologic order of events; setting and circumstances (e.g., while exercising, sleeping, working); manner of the onset (sudden versus gradual)
Location: exact location of pain (localized, generalized, radiation patterns)
Duration: length of problem or episode; if intermittent, duration of each episode
Character: nature of pain (e.g., stabbing, burning, sharp, dull, gnawing)
Aggravating and associated factors: food, activity, rest, certain movements; nausea, vomiting, diarrhea, fever, chills
Relieving factors and effect on the problem: food, rest, activity, position, prescribed and/or home remedies, alternative or complementary therapies
Temporal factors: frequency of occurrence (single attack, intermittent, chronic); describe typical attack; change in symptom intensity, improvement or worsening over time
Severity of the symptoms: 0 to 10 scale, effect on lifestyle, work performance

Recording the History of the Present Illness: OLDCARTS

The OLDCARTS mnemonic helps make sure all characteristics of a problem are described in the history of present illness (HPI) to ensure a comprehensive presentation. The order of recording these characteristics does not need to be consistent.

O nset
L ocation
D uration
C haracter
A ggravating/associated factors
R elieving factors
T emporal factors
S everity of symptoms

Past Medical History

The past medical history (PMH) includes general health over the patient’s lifetime and disabilities and functional limitations, as the patient perceives them. List and describe each of the following with dates of occurrence and any specific information available:

Hospitalizations and/or surgery (including outpatient surgery): dates, hospital, diagnosis, complications, injuries, disabilities
Major childhood illnesses: congenital heart defects, previous cancer, inflammatory bowel disease, asthma
Major adult illnesses: tuberculosis, hepatitis, diabetes mellitus, hypertension, myocardial infarction, tropical or parasitic diseases, other infections
Serious injuries: traumatic brain injury, liver laceration, spinal injury, fractures
Immunizations: polio, diphtheria, pertussis, tetanus toxoid, hepatitis B, measles, mumps, rubella, Haemophilus influenzae, varicella, influenza, hepatitis A, meningococcal, human papillomavirus, pneumococcal, zoster, cholera, typhus, typhoid, anthrax, smallpox, Bacille Calmette-Guérin (BCG), unusual reaction to immunizations
Medications: past, current, and recent medications (dosage, nonprescription medications, vitamins); complementary and herbal therapies
Allergies: drugs, foods, environmental allergens, along with the allergic reaction (e.g., rash, anaphylaxis)
Transfusions: reason, date, and number of units transfused; reaction, if any
Mental health: mood disorders, psychiatric therapy, or medications
Recent laboratory tests: glucose, cholesterol, Pap smear/HPV, HIV, mammogram, colonoscopy

Family History

Include a pedigree (with at least three generations). An example is shown in Fig. 5.2 . Many EHRs allow healthcare providers to create a pedigree. If it is not part of the pedigree, include a family history of major health or genetic disorders (e.g., hypertension, cancer, cardiac, respiratory, kidney disease, strokes, or thyroid disorders; asthma or other allergic manifestations; blood dyscrasias; psychiatric illness; tuberculosis; rheumatologic diseases; diabetes mellitus; hepatitis; or other familial disorders). Spontaneous abortions and stillbirths suggest genetic problems. Include the age and health of the spouse and children.

FIG. 5.2, (A) Common pedigree symbols. (B) Sample pedigree for autosomal recessive condition.

Personal and Social History

The information included in this section varies according to the concerns of the patient and the influence of the health problem on the patient’s life.

Cultural background and practices, birthplace, where raised, home environment as youth, education, position in family, marital status, general life satisfaction, hobbies, interests, sources of stress, religious preference (religious or cultural proscriptions concerning medical care)
Home environment: number of individuals in household, pets, economic condition
Occupation: usual work and present work if different, list of job changes, work conditions and hours, physical or mental strain, duration of employment; present and past exposure to heat and cold, industrial toxins; protective devices required or used; military service
Environment: home, school, work, structural barriers if physically disabled, community services utilized; travel and other exposure to contagious diseases, residence in tropics; water and milk supply, other sources of infection when applicable
Current health habits and/or risk factors: exercise; smoking (packs per day times duration); salt intake; obesity/weight control; diet; alcohol intake: beer, wine, hard liquor (amount/day), duration; CAGE (see Box 1.3 ) or TACE (see Box 1.4 ) question responses; blackouts, seizures, or delirium tremens; drug or alcohol treatment program or support group; illicit drugs used (e.g., marijuana, cocaine, heroin, LSD, PCP, methamphetamine) and methods (e.g., injection, ingestion, sniffing, smoking, or use of shared needles)
Exposure to chemicals, toxins, poisons, asbestos, or radioactive material at home or work and duration; caffeine use (cups or glasses/day)
Military service record: branch of service, military occupational specialty/job in the military, dates and geographic area of assignments/deployments, current status (active duty, reserves, retired, veteran)
Sexual activity: contraceptive or barrier protection method used; past sexually transmitted infections (e.g., syphilis, gonorrhea, chlamydia, pelvic inflammatory disease, herpes, warts); treatment
Concerns about cost of care, healthcare coverage

Review of Systems

General constitutional symptoms: fever, chills, malaise, easily fatigued, night sweats, weight (average, preferred, present, change over a specified period and whether this change was intentional)
Skin, hair, and nails: rash or eruption, itching, pigmentation or texture change; excessive sweating, unusual nail or hair growth
Head and neck: frequent or unusual headaches, their location, dizziness, syncope; brain injuries, concussions, loss of consciousness (momentary or prolonged)
Eyes: visual acuity, blurring, double vision, light sensitivity, pain, change in appearance or vision; use of glasses/contacts, eye drops, other medication; history of trauma, glaucoma, cataracts, familial eye disease
Ears: hearing loss, pain, discharge, tinnitus, vertigo
Nose: sense of smell, frequency of colds, obstruction, nosebleeds, postnasal discharge, sinus pain
Throat and mouth: hoarseness or change in voice; frequent sore throats, bleeding or swelling of gums; recent tooth abscesses or extraction; soreness of tongue or buccal mucosa, ulcers; disturbance of taste
Lymphatic: enlargement, tenderness, suppuration
Chest and lungs: pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum (character and quantity), hemoptysis, night sweats, exposure to tuberculosis; last chest radiograph
Breasts: development, pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening or diagnostic)
Heart and blood vessels: chest pain or distress, precipitating causes, timing and duration, relieving factors, palpitations, dyspnea, orthopnea (number of pillows), edema, hypertension, previous myocardial infarction, exercise tolerance (flights of steps, distance walking), past electrocardiogram and cardiac tests
Peripheral vasculature: claudication (frequency, severity), tendency to bruise or bleed, thromboses, thrombophlebitis
Hematologic: anemia, any known blood cell disorder
Gastrointestinal: appetite, digestion, intolerance of any foods, dysphagia, heartburn, nausea, vomiting, hematemesis, bowel regularity, constipation, diarrhea, change in stool color or contents (clay, tarry, fresh blood, mucus, undigested food), flatulence, hemorrhoids, hepatitis, jaundice, dark urine; history of ulcer, gallstones, polyps, tumor; previous radiographic studies, sigmoidoscopy, colonoscopy (where, when, findings)
Diet: appetite, likes and dislikes, restrictions (because of religion, allergy, or other disease), vitamins and other supplements, caffeine-containing beverages (coffee, tea, cola); food diary or daily listing of food and liquid intake as needed
Endocrine: thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polydipsia, polyuria, changes in facial or body hair, increased hat and glove size, skin striae
Assigned male at birth: puberty onset, erections, emissions, testicular pain, libido, infertility
Assigned female at birth: menses onset, regularity, duration, amount of flow; dysmenorrhea; last period; intermenstrual discharge or bleeding; itching; date of last Pap smear/HPV test; age at menopause; libido; frequency of intercourse; sexual difficulties
Pregnancy: infertility; gravidity and parity (G = number of pregnancies, P = number of childbirths, A = number of abortions/miscarriages, L = number of living children); number and duration of each pregnancy, delivery method; complications during any pregnancy or postpartum period; use of oral or other contraceptives
Genitourinary: dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone, edema of face, stress incontinence, hernias, sexually transmitted infection
Musculoskeletal: joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity, number and pattern of joint involvement
Neurologic: syncope, seizures, weakness or paralysis, problems with sensation or coordination, tremors
Mental health: depression, mania, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep disturbances

Physical Examination Findings

Record the objective data by body systems and anatomic location. Begin with a general statement about the overall health status of the patient. All observations of physical signs should be described in the appropriate body system or region, usually organized in sequence from head to toe. Take care to describe findings in detail rather than make diagnostic statements. The findings generally included in each category follow.

General Statement

Age, general appearance
Weight, height, body mass index
Vital signs: pain score and location of pain if present, temperature, pulse rate, respiratory rate, and blood pressure.
When appropriate you should include pulse oximetry reading and orthostatic (lying, sitting, and standing) pulse and blood pressure

Mental Status

Physical appearance and behavior
Cognitive: consciousness level, response to questions, reasoning or judgment, arithmetic ability, memory, attention span, specific mental test scores
Emotional stability: depression, anxiety, disturbance in thought content, hallucinations
Speech and language: voice quality, articulation, coherence, comprehension

Skin

Color, uniformity, integrity, texture, temperature, turgor, hygiene, tattoos, scars
Presence of edema, moisture, excessive perspiration, unusual odor
Presence and description of lesions (size, shape, location, color, configuration, blanching, inflammation, tenderness, induration, discharge), trauma
Hair texture, distribution, color, quality
Nail configuration, color, texture, condition, nail base angle for clubbing, ridging, beading, pitting, peeling, nail plate firmness, adherence to nail bed

Head

Size and contour of head, scalp appearance, head position
Symmetry and spacing of facial features, tics, characteristic facies
Presence of edema or puffiness
Temporal arteries: pulsations, thickening, hardness, tenderness, bruits

Eyes

Visual acuity (near, distant), visual fields
Appearance of orbits (edema, sagging tissue, puffiness), color of conjunctivae and sclerae, eyelids (redness, flakiness, fasciculations, ptosis), eyebrows
Extraocular movements, corneal light reflex, cover-uncover test, nystagmus
Pupillary shape, size, consensual response to light and accommodation, depth of anterior chamber
Ophthalmoscopic findings of cornea, lens, retina, red reflex, optic disc and macular characteristics, retinal vessel size, caliber, and arteriovenous (AV) crossings, arteriole-venule ratio, exudates, hemorrhages

Ears

Configuration, position, and alignment of auricles; nodules; tenderness of auricles, or in mastoid area
Otoscopic findings of canals (cerumen, lesions, discharge, foreign body) and tympanic membranes (integrity, color, bony landmarks, light reflex, mobility, bulging, retraction), fluid, air bubbles
Hearing: Weber and Rinne tests, whispered voice, conversation

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