
Chief Complaint o Host: age, gender, key identifying facts (pertinent medical history, job) o Reason for admission (patient’s words or key problem)

Source of Information

History of Present Illness o Begins with usual state of health o Orderly Progression o Pertinent negatives o Culmination in admission (emergency room course, prior hospital course)

Past Medical History (detail varies with pertinence)

Medications (prescribed, over the counter, supplements, and alternatives)

Social History o Work, hobbies (especially something interesting) o Habits (alcohol, cigarettes, drugs) o Sexual history o Travel history o Living situation (where, with whom)

Family History (relevant findings only)

Review of Systems (relevant findings only)

Physical Exam (Detail may vary w/clinical needs and attending expectations) o General Appearance o Vital Signs o Physical Findings

Diagnostic Studies (details may vary w/clinical needs and attending’s expectations) o Blood Work o Urinalysis o EKG o Imaging studies o Other

Summary (salient points)

Impression o Differential diagnosis o Weigh pros and cons of reasonable diagnostic possibilities

Plan by Issue o Work up (consultations, diagnostic testing) o Treatment

Chief Complaint o Host: age, gender, key identifying facts (pertinent medical history, job) o Reason for admission (patient’s words or key problem)

Source of Information

History of Present Illness o Begins with usual state of health o Orderly Progression o Pertinent negatives o Culmination in admission (emergency room course, prior hospital course)

Past Medical History (detail varies with pertinence)

Medications (prescribed, over the counter, supplements, and alternatives)

Social History o Work, hobbies (especially something interesting) o Habits (alcohol, cigarettes, drugs) o Sexual history o Travel history o Living situation (where, with whom)

Family History (relevant findings only)

Review of Systems (relevant findings only)

Physical Exam (Detail may vary w/clinical needs and attending expectations) o General Appearance o Vital Signs o Physical Findings

Diagnostic Studies (details may vary w/clinical needs and attending’s expectations) o Blood Work o Urinalysis o EKG o Imaging studies o Other

Summary (salient points)

Impression o Differential diagnosis o Weigh pros and cons of reasonable diagnostic possibilities

Plan by Issue o Work up (consultations, diagnostic testing) o Treatment