Scribd
Upload
615 views

Hpi Cheat Sheet PDF

The document provides guidance on obtaining a comprehensive patient history, including sections to document identifying information, the chief concern, history of present illness, past medical history, family history, social history, risk factors, and a review of systems. It recommends collecting data on characteristics, onset, symptoms, exacerbating and relieving factors for the chief concern. Sections are included to thoroughly document the patient's medical background, family history, lifestyle, and review body systems for any associated symptoms.

Uploaded by

Timothy Harwich
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
615 views

Hpi Cheat Sheet PDF

The document provides guidance on obtaining a comprehensive patient history, including sections to document identifying information, the chief concern, history of present illness, past medical history, family history, social history, risk factors, and a review of systems. It recommends collecting data on characteristics, onset, symptoms, exacerbating and relieving factors for the chief concern. Sections are included to thoroughly document the patient's medical background, family history, lifestyle, and review body systems for any associated symptoms.

Uploaded by

Timothy Harwich
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

A Guide to Obtaining a Patient History

www.medicalminded.com

Identifying Data
- Date
- Age
- Gender
- Ethnicity

Chief Concern: Reported in the patient’s own words

History of Present Illness (HPI)


“It’s time to get CLOSER to a diagnosis!”
- Characteristics
- Location
- Onset and duration
- Symptoms associated with main concern
- Exacerbating factors
- Relieving factors
*Include a Review of Systems for pertinent information (see next pg.)

Past Medical History


“Med-Surg, Trauma, Hospitilizations,
Gyne, Allergies, and Medications
And don’t forget Immunizations!”
- Medical history
- Surgical history
- Trauma history
- Gynecological/Obstetric
- Allergies
- Medications
- Immunizations

*Include growth/development and childhood illness if applicable.

Family Medical History


Summary of physical health and ages of first degree family members

Personal/Social History
- Relationships/Marriage
- Living Situation
- Social Support
- Personal Background
- Directives for Care

Prevention/Risk Factors
“Prevention Oriented Doctors Advise Safe Sex”
- Prevention: exercise, recreational activities, firearm safety, seatbelt safety, stress, sleep
- Occupational hazards
- Drugs: tobacco and recreational drug use
- Alcohol
- Safe from violence: Do you feel safe? Has anyone ever hurt you?
- Sexual history: partners (male/female/both), practice safe sex, history of STD
Review of Systems
“Head to toe is the way to go!”
It’s easier to remember to ask about specific symptoms if you do it the same way each time. One of the
easier methods is to ask system-based questions from “head to toe”. Start with symptoms relating to
the head, then the neck, then chest/arms/legs, stomach, etc. until you get all the way to the toes.
- Example: Are you experiencing any… headaches, blurry vision, sore throat, coughing, difficulty
breathing, vomiting, abdominal pain, diarrhea, etc.

- General
- Skin
- Endocrine
- Hematopoietic
- Musculoskeletal
- Head and Neck
- Eyes
- Ears, Nose, Sinuses, Mouth and Throat
- Breasts
- Respiratory
- Cardiovascular
- Gastrointestinal
- Urinary
- Female reproductive
- Male reproductive
- Neurologic
- Psychiatric

You might also like