Medical Record

Question 1

Components of the medical record

Answer 1

chief complaint, history of present illness, past medical history, review of systems, physical examination, laboratory and imaging data, diagnosis, and disposition

Question 2

chief complaint (CC)

Answer 2

why the patient is seeking medical attention, subjective, notated in the patients’ own words,

Question 3

history of present illness (HPI)

Answer 3

patient interview with open ended questions, chronological narrative of subjective complaint(s), utilizes OPQRST or OLD CARTS

Question 4

OPQRST

Answer 4

Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time

Question 5

OLD CARTS

Answer 5

Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Time, Severity

Question 6

past medical history (PMH)

Answer 6

facts of the patient’s history from the following categories: medical, surgical, medications, allergies, vaccinations, social history, and family history

Question 7

review of systems (ROS)

Answer 7

subjective review of each body system, highlights pertinent positive or negative responses surrounding current CC/HPI

Question 8

physical exam

Answer 8

objective data that includes vital signs and IPPA

Question 9

IPPA

Answer 9

Inspection, Palpation, Percussion, and Auscultation

Question 10

diagnosis

Answer 10

-identification of illness/disease/problem
-utilizes info from patient’s history, subjective, and objective data for conclusion
-helps to guide treatment plan and disposition
-differential diagnosis: list of possible causes/diseases/illnesses

Question 11

disposition

Answer 11

-plan of care for the patient
-will the patient require further imaging, lab tests, etc
-will the patient require treatment/medication
-where will this patient need to go for further medical care (ex: primary doctor, hospital admit, ICU admit, etc.)