Health History & Documentation

Question 1

What is subjective data? Give some examples

Answer 1

Anything the patient tells you about their symptoms

Information from any source that hard data cannot verify - family, social, illness/health history

Patient experiences: SOB, pain, fatigue

Question 2

What is objective data? Give some examples.

Answer 2

Hard data from physical exams, labs, diagnostic tests.

Examples: vital signs, weight, height, anything you feel, hear, and smell.

Question 3

What is OLD CARTS and what does it stand for?

Answer 3

OLD CARTS is a helpful mnemonic for characterizing the chief complaint.

Onset
Location
Duration
Character
Aggravating or Alleviating Factors
Radiation
Timing
Setting

Question 4

What is OPQRST?

Answer 4

OPQRST is a helpful mnemonic for characterizing the chief complaint.

Onset
Precipitating and Palliating Factors
Quality
Region or Radiation
Severity
Timing or Temporal Characteristics

Question 5

What are pertinent positives?

Answer 5

Signs and symptoms you would expect to find if a possible cause for a patient’s problem were true.

Example for SOB, + fever, + cough with sputum

Question 6

What are pertinent negatives?

Answer 6

Signs and symptoms that are NOT present. Help to rule in or out differential diagnoses.

Example for SOB:
- chest pain
- nausea/vomiting/diarrhea

Question 7

What does FIFE stand for?

Answer 7

Feelings
Ideas
Functions
Expectations