1. Chief Complaint the primary problem that prompted the client to schedule a visit.
Use the client's own words.
2. History of Pre- is a concise, clear, and chronological description of the chief complaint which
sent Illness prompted the client's visit. A symptom analysis guided by the mnemonic "OLD-
CARTS" will reveal information regarding the onset, location, duration, character-
istics, aggravating factors, relieving factors, treatments, and severity of the symp-
toms.
3. Pertinent posi- symptoms that are expected with a potential diagnosis related to the chief com-
tives plaint.
4. Pertinent nega- symptoms the client does not have that are expected with a potential diagnosis
tives related to the chief complaint.
5. OLDCARTS onset, location, duration, characteristics, aggravating factors, relieving factors,
treatments, and severity of the symptoms.
6. Onset "When did this start?"
7. Location "Where did the problem start; does it move anywhere?"
8. Duration "How long does the problem last or is it constant?"
9. Characteristics "Can you describe what the problem feels like?"
10. Aggravating Fac- "Does anything make it worse?"
tors
11. Relieving Factors "Does anything make it better?"
12. Treatments "Have you taken any medications or nonpharmaceutical treatments for this prob-
lem?"
13. "How bothersome is this problem?"
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