- Patient Medical Charting Guidelines
- Health History Considerations
- Current Health Status Intake Questions
- Past Health History Questions
Health History Assessment Purpose
- A detailed patient history is the most useful diagnostic tool available to any clinician.
- The main purpose of the patient’s history is to determine the patient’s motives for seeking health care and how their specific ailment is interfering with their daily life.
- Surveys show that more than 80% of the diagnosis in general outpatient clinics are based on patient interview based on health history assessment.
- The patient interview should continue through the entire duration of the interaction with them.
- The best general patient history technique is to start with open ended questions, and eventual progress to close-ended questions for details.
- The accuracy of information collected from the patient during the interview (and exam) influence the precision of your diagnosis and treatment.
Patient Medical Charting Guidelines
- All chart records must remain confidential.
- Charting must be clear and legible in order to be useful.
- Do not erase mistakes or remove pages from the chart. If you must erase an error from the patient’s chart, draw a single line through the error/s and initial.
- If you saw it or did it, chart it.
- Charting should be done in black ink, labeled, dated and signed by the clinician who examined the patient.
Health History Considerations
Red Flags for More Serious Pathology
- Violent trauma
- Systemic steroid use
- Drug abuse
- HIV, Hepatitis
- Recent unexplained weight loss
- Constant, progressive non-mechanical pain
- Bowel and/or bladder dysfunction
Signs and Symptoms Red Flags for More Serious Pathology
- Temperature > 100° F/37.8°C
- Blood pressure > 160/95 mm Hg
- Resting pulse > 100 bpm
- Resting respiration > 25 bpm
- Auscultation of bruits – carotid, abdominal
- Widespread neurological deficits
- Saddle anaesthesia
Health History Intake Questions
- What is your occupation?
- Describe your activities at work. Hours?
- Do you like your job?
- Describe your overall fitness level.
- Do you participate in regular exercise? (describe type, intensity & frequency)
- Do you have any other interests, hobbies or activities you enjoy?
- Rate your overall diet for me (good, fair, poor)
- What do you eat for … breakfast? Lunch? Dinner? Snacks?
- What do you drink throughout the day?
- How often do you eat … vegetables? Fruit? Sweets? Fast food?
- How much water do you drink a day?
- Can you describe your living situation to me? (house/apt., relationships, etc.)
- How many hours do you sleep each night?
- Have there been any recent changes?
- Do you feel you get enough sleep?
- How often do you have a bowel movement? Any recent changes?
Patients over 50
Do you ever notice any rectal bleeding?
- Do you have any problems with urination? Any recent changes? (stopping or starting)
Alcohol: Do you drink alcohol? Type?
How often do you drink? How much?
If you have concern about patient’s drinking:
- Have you ever felt the need to cut down on drinking?
- Have you ever felt Annoyed by criticism of drinking?
- Have you had Guilty feelings about drinking?
- Have you ever taken a morning “Eye opener?”
- Do you use or have you ever used tobacco products/smoke? What do you use?
- How much do you smoke? For how long? When did you stop?
- Do you use any recreational drugs? What? For how long? (reiterate patient confidentiality if needed)
- Are you currently or have you ever been in a relationship where you were physically hurt or made to feel threatened?
- When was the first day of your last menstrual period?
- Do you have any problems with your menstrual cycle?
- Have there been any changes in your menstrual cycle? Any abnormal bleeding?
Patients over 50:
- Are you still having menstrual periods? If yes, do you remember the first day of your last menstrual period?
- At what age did you experience menopause?
- Did you/are you taking hormone replacement?
- What? How is it administered?
- Why did you have a hysterectomy? (Cancer?)
- Did they remove your ovaries?
- Are you taking hormone replacement?
What medication? How is it administered?
- Contraceptives: Are you using any kind of hormonal contraceptive or an IUD? If yes, what & any problems?
- Pregnancies: Have you ever been pregnant? If yes, were there any complications?
- Do you take any prescribed medications?
- Do you take any over the counter medications?
- Do you take any vitamins?
- Have you ever taken medication for extended periods of time?
- E.g., Steroids, antidepressants, NSAIDs, antibiotics, hormones
- Do you have any allergies? Food, meds, seasonal
Stress factors/Support System
- Have there been any significant stresses in your life lately? (e.g.deaths, divorce, family, work)
- Have you noticed a change in your ability to handle stress?
- What resources do you have for support for…?
Past Health History Questions
- Have you ever had any serious illness(es)?
- Any other problems? Residual effects?
- Have you ever been hospitalized?
- Have you had any surgeries?
General Trauma, Accidents, Injury
- Have you experienced any physical trauma that required treatment or should have been treated?
- Have you had any accidents? MVA?
- Were there any residual problems or prolonged side effects?
Diagnostic Imaging (x-ray, MRI)
- Have you ever had any x-rays? If yes, why?
- Were there any problems identified on the x-ray?
- Have you ever received prior care?
- If yes, what for? Describe the care. Did it help?
- This will tell what has & has not worked previously (huge clinical value)
Last Physical Exam
- When was your last physical exam? Were you experiencing your chief complaint when you had the physical?
- What was it for?
- Were any problems identified?
- When was your last GYN exam & PAP smear?
- What were the results?
Females over 50:
- Have you had a mammogram? How often?
- What were the results?
- Do you perform self-testicular exam?
- Have you ever been taught how to?
Males over 40:
Have you ever had a rectal exam or lab tests to evaluate your prostate?
- If yes, do you remember the results?
Family Health History
- Are there any conditions that run in your family (diabetes, high blood pressure, stroke, heart disease, cancer)
- I’d like to start with your mother. Is she alive? Does she have any health problems?
- How about your mother’s mother?
- How about your mother’s father?
- Your father? Your father’s mother? Your father’s father? Brothers? Sisters?
- If there is a deceased relative, how old were they when they died? Cause of death?
- Any other health problems in the family?
- Consider using a family tree in chart notes