©THEBRIGHTSTARS 2024
Documentation of a Patient Interview Exam
Questions With Correct Answers
What are all of the major parts to the documentation of a patient interview? (11 items) -
answer✔✔1. Patient Identification
2. Chief Complaint
3. HPI
-3a. Opening sentence
-3b. Analysis of all symptoms [OLD CARTS]
-3c. *Pertinent* past medical, family, social history & ROS)
4. Medications
5. Allergies
6. Past Medical History
7. Family History
8. Psychosocial History
9. Review of Systems
10. Assessment/Plan
11. Signature & Attending Statement
What should be included in the patient identification section? (6 items) - answer✔✔1) Name
2) DOB
3) Age
4) Gender
5) Patient reliability
6) Use of an interpreter
, ©THEBRIGHTSTARS 2024
4 Things to remember about documenting the chief complaint - answer✔✔1) If it's a well visit,
they may not have a chief complaint. Write "Routine physical examination."
2) The #1 reason the patient is seeking medical attention. A concise, one-line opening phrase that
includes patient's presenting concern and duration from onset.
3) The duration should be a fairly short period of time. If longer, find out reason they came in
and list that.
4) Put the CC in the patient's own words if possible.
Eg. "I have food poisoning" x 4 hours
3 Things to remember about documenting the HPI - answer✔✔1) Detailed background
information *relevant* to chief complaint.
2) Concise, clear, and easily comprehended.
3) Includes opening sentence, analysis of all symptoms (OLD CARTS), and *pertinent* past
medical, family, social history & ROS.
What should be included in the opening sentence? - answer✔✔Patient's age, race, gender,
chronic adult illnesses, smoking status, description of setting (office, ED), manner if relevant that
patient arrived at location (EMS, escorted by police), and reason for visit (re-state CC). If no CC,
include an additional summary statement of patient's perceived health status.
Eg. "This is a 66 y/o AAM non-smoker with PMH of hypertension and coronary artery disease
presenting to the office for a routine physical examination. He states that his health status is per
baseline, and he denies any recent medical changes."
OLDCARTS - answer✔✔Onset
Location
Duration
Characteristics
Aggravating, Alleviating, Associated symptoms
Radiation
Temporal pattern
Severity
4 Questions to ask about Onset - answer✔✔*Manner of onset (sudden or gradual):* How did the
pain/symptoms begin? Did they come on suddenly or gradually?
*Time of onset:* When was the onset?
Documentation of a Patient Interview Exam
Questions With Correct Answers
What are all of the major parts to the documentation of a patient interview? (11 items) -
answer✔✔1. Patient Identification
2. Chief Complaint
3. HPI
-3a. Opening sentence
-3b. Analysis of all symptoms [OLD CARTS]
-3c. *Pertinent* past medical, family, social history & ROS)
4. Medications
5. Allergies
6. Past Medical History
7. Family History
8. Psychosocial History
9. Review of Systems
10. Assessment/Plan
11. Signature & Attending Statement
What should be included in the patient identification section? (6 items) - answer✔✔1) Name
2) DOB
3) Age
4) Gender
5) Patient reliability
6) Use of an interpreter
, ©THEBRIGHTSTARS 2024
4 Things to remember about documenting the chief complaint - answer✔✔1) If it's a well visit,
they may not have a chief complaint. Write "Routine physical examination."
2) The #1 reason the patient is seeking medical attention. A concise, one-line opening phrase that
includes patient's presenting concern and duration from onset.
3) The duration should be a fairly short period of time. If longer, find out reason they came in
and list that.
4) Put the CC in the patient's own words if possible.
Eg. "I have food poisoning" x 4 hours
3 Things to remember about documenting the HPI - answer✔✔1) Detailed background
information *relevant* to chief complaint.
2) Concise, clear, and easily comprehended.
3) Includes opening sentence, analysis of all symptoms (OLD CARTS), and *pertinent* past
medical, family, social history & ROS.
What should be included in the opening sentence? - answer✔✔Patient's age, race, gender,
chronic adult illnesses, smoking status, description of setting (office, ED), manner if relevant that
patient arrived at location (EMS, escorted by police), and reason for visit (re-state CC). If no CC,
include an additional summary statement of patient's perceived health status.
Eg. "This is a 66 y/o AAM non-smoker with PMH of hypertension and coronary artery disease
presenting to the office for a routine physical examination. He states that his health status is per
baseline, and he denies any recent medical changes."
OLDCARTS - answer✔✔Onset
Location
Duration
Characteristics
Aggravating, Alleviating, Associated symptoms
Radiation
Temporal pattern
Severity
4 Questions to ask about Onset - answer✔✔*Manner of onset (sudden or gradual):* How did the
pain/symptoms begin? Did they come on suddenly or gradually?
*Time of onset:* When was the onset?
