CH 4 The Complete Health History

Question 1

Health History Sequence (8-steps)

Answer 1

1. Biographic data
2. Reason for seeking care (chief complaint)
3. History of Present Illness (HPI) (story of why they are coming in with chief complaint)
4. Past medical history
5. Medical Reconciliation (which meds? dosage? compliance?)
6. Family history
7. Review of System (ROS) (head-to-toes review of each system based on patient’s perception)
8. Functional Assessment, including ADLs (activities of daily living)

Question 2

History of Present Illness (HPI) - How to Document

Answer 2

OLDCARTS
O (onset)
L (location)
D (duration)
C (character) (description)
A (aggravating factors)
R (relieving factors) 
T (treatment)
S (severity)

Question 3

Review of Systems (ROS) - Order of Systems for Review (15 categories)

Answer 3

General Survey –> Skin, hair, nails –> HEENT –> Neck –> Breast & Axilla –> Respiratory –> Cardiac –> Peripheral Vascular –> GI –> GU –> Sexual Health –> Musculoskeletal –> Neuro –> Hematologic –> Endocrine

Question 4

Functional Assessment, including ADLs (14 categories)

Answer 4

ADLs: bathing, dressing, toileting, eating, walking –> Self-esteem –> Activity/exercise –> Sleep/rest –> Nutrition –> Interpersonal Relationships –> Spiritual Resources –> Stress Management –> Personal Habits –> Alcohol use –> Drug Use –> Environmental –> Intimate Partner Violence (IPV) –> Occupational Health