1. Chief Complaint: the primary problem that prompted the client to
schedule a visit. Use the client's own words.
2. History of Present Illness: is a concise, clear, and chronological description of the
chief complaint which prompted the client's visit. A symptom analysis guided by the mnemonic
"OLDCARTS" will reveal information regarding the onset, location, duration, characteristics, aggravating
factors, relieving factors, treatments, and severity of the symptoms.
3. Pertinent positives: symptoms that are expected with a potential diagnosis related to the chief
complaint.
4. Pertinent negatives: symptoms the client does not have that are expected with a potential
diagnosis 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?"
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, 9. Characteristics: "Can you describe what the problem feels like?"
10. Aggravating Factors: "Does anything make it worse?"
11. Relieving Factors: "Does anything make it better?"
12. Treatments: "Have you taken any medications or nonpharmaceutical treatments for this
problem?"
13. Severity of the Symptoms: "How bothersome is this problem?"
14. Childhood Illnesses: Inquire about childhood illnesses such as measles, chickenpox, or
scarlet fever and chronic childhood illnesses such as diabetes or asthma.
15. Adult Illnesses: Inquire about illnesses such as diabetes, hypertension, or asthma and
hospitalizations.
16. Surgical: Document dates, indications, and types of surgical procedures.
17. Obstetric/Gynecologic: Document number of pregnancies (gravida), number of
deliveries (para-term, preterm, abortions, and living children), menstrual history, methods of
contraception, and sexual function.
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