Medical Transcription Services Company

CHIEF COMPLAINT (CC):   What the patient says is wrong.

HISTORY OF PRESENT ILLNESS (HPI):   A description of what the current problem is.

PAST MEDICAL HISTORY (PMH):   What diseases or problems patient had in the past.

SURGICAL HISTORY (SH):   Surgeries the patient had in the past (sometimes is included in PMH).

ALLERGIES:   What medications or substances may have led to an allergic reaction, (sometimes included in PMH).

IMMUNIZATIONS:  Sometimes but not always listed in a separate category; may be included in PMH.

FAMILY HISTORY:   A history of the diseases/problems in the patient's immediate family.

SOCIAL HISTORY:   Education, work, geographic, biographic, marital status; children, smoking, drinking, habits, hobbies, recreation, etc.

REVIEW OF SYSTEMS (ROS):   A general review of each of the body systems, though typically only those systems, which are creating problems are discussed.

PHYSICAL EXAMINATION (PE):   In the history–physical exam, the examination follows the headings below.

GENERAL:   How the patient appears; anything notable.
VITAL SIGNS:   Blood pressure, heart rate, respiratory rate.
HEENT:   Head, eyes, ears, nose and throat.
NECK:   Describes the neck, pulses, glands, etc.
CHEST:   Can describe the lungs, heart, breasts, sometimes just the heart and lungs with breasts as a separate heading.
BREASTS:   Are generally broken out from CHEST as separate headings.
ABDOMEN:   Describes the look and palpation of the organs located here.
EXTREMITIES:   Arms, hands, legs and feet.
GENITALIA:   Describes the genitalia - both external and internal.
RECTAL:   Exam of the rectum.
NEUROLOGICAL:   Exam of the neurologic status.

LABORATORY DATA:   The laboratory data consists of those exams which have been done in the office prior to admission or in the emergency room or outpatient department preceding admission.

IMPRESSION:   The summary of what the admitting care provider thinks is wrong with the patient (working diagnoses).

PLAN:   What the doctor plans for the patient to undergo at this point and in the subsequent hospital workup process.

Quick Inquiry
Name
Phone
Email
Description
Type the code shown below

Bookmark-www.brainstormworld.com