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Patient Chart

INFORMATION IN PATIENT CHART


1.PATIENT DEMOGRAPHICS- Patient Name, Age, Gender, Status, Address, Occupation, Religion

2.CHIEF COMPLAINT (CC)- 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 chronologic description of the development of the Pt's present illness
Carson Johnson is a 67-year-old African-American man admitted in the emergency room at 8:45 AM after noticing a sudden
onset of weakness in his right arm. He woke up at 7:15 AM and went to the bathroom to brush his teeth. While walking from
the bathroom to the kitchen, he noticed general weakness and had trouble saying “good morning” to his son, with whom he
lives. His son immediately brought him to the ER. While in the ER, he started to have a rightsided facial droop. He denied any
dizziness, vomiting, or headache.
This is the first admission for this 13-month-old white boy who was felt to be well until approximately 3 weeks ago when his
stools became loose and frequent. This problem persisted with three to four stools daily until three days ago when he
developed a fever (documented only by his mother's feeling that he was warm). The stools became green and "slimy" although
the frequency remained unchanged. His intake of fluids consisted of three 3-oz. bottles of whole milk. No solids were tolerated.
On the day of admission the baby did not take any feedings. He vomited twice admitted to the hospital. No fever was noted.
His responsiveness had decreased to the point of unresponsiveness. On arrival in the emergency room he was immediately
given an intravenous bolus of normal saline and admitted to the ward.

4. PAST MEDICAL HISTORY- prior illnesses, their treatments


In 1996, Lucy experienced a minor stroke, which caused temporary paralysis in her left arm. She was monitored in hospital for
three weeks and recovered. 3 years ago, Lucy was diagnosed as lupus carrier. Since the diagnosis, Lucy has been taking
Warfarin and she expects to maintain Warfarin therapy for life. Her condition has exacerbated a series of endotheliopathies,
predisposing Lucy to retinal microvascular occlusion.

5.FAMILY HISTORY - present health or cause of death of parents, brothers, sisters

6.SOCIAL HISTORY - 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 organized and complete examination of a Pt's organ systems
“Do you have any problems breathing?” “Do you have shortness of breath when exercising, walking, climbing the stairs?”
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.”
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 .

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