Module 1: Health History and
Documentation
Types of Medical Documentation (Notes) - ANSComprehensive History and Physical Exam Note
Focused History and Physical Exam Note
SOAP Note
Progress Note
Transition of Care Note
Procedure Note
Types of Medical Documentation (Notes): Comprehensive History and Physical Exam Note -
ANS-Need to know how to do all portions of this exam - includes a lot of things
-Will take you through everything
source of fundamental and personalized knowledge about the pt that strengthens the
clinician-patient relationship
-all the info about the pt, identifying info all the way through CC and HPI, PMH, Social Hx,
Exam, assessment/problem list, treatment plans/regular plans (sexual health, spiritual, etc) =
yearly physical - one time a year going through everything
Types of Medical Documentation (Notes): Focused History and Physical Exam Note -
ANShappen in urgent care/ER/pt family practice/internal medicine and follow up; pt seeking
care for specific concerns (ex. cough, painful urination), a more limited interview tailored to that
specific problem
- use in places at Urgent care, ER's or if you are following up with pt (pt you already know if
PCP and peds) - pt comes in with a specific concern - show up 3 months down the road bc they
have a new complaint (hurt ankle, sore throat)
Types of Medical Documentation (Notes): SOAP Note - ANSdocumentation: subjective,
objective, assessment, and plan - how the note is structured
-for follow up info or exam - pt comes in and has hypertension and see if medications have been
helping - CC, HPI and brief review of system (doesn't include F/S hx)
Types of Medical Documentation (Notes): Progress Note - ANSin patient/follow up visits -
addressing concern pt has - come back for a follow up visit
part of a medical record where healthcare professionals record details to document a patient's
clinical status or achievements during the course of a hospitalization or over the course of
outpatient care
- follow same format of SOAP - in patient notes - writing every day - add in a daily update as
whole hx isn't changing daily
,Types of Medical Documentation (Notes): Transition of Care Note - ANSpt needs to be
transitioned to different level of care ex. ICU to regular floor or from hospital to extended care
facility or DC summary that will be sent to PCP
- write when pt is transitioning level of care: pt is going out of the hospital (DC summary - note
sent to PCP/specialties), changing levels of care at the hospital - into or out of ICU - like SOAP
but also why they are able to move into or out of the hospital/ICU/hospital to extended care
facility/nursing home - person leaves your care you are writing a ___ Note - intake when they
come in and when they come out
Types of Medical Documentation (Notes): Procedure Note - ANSnote you write when you do a
procedure - what, why, and how
supplement to PN or History and Physical note - what procedure was done - what, why, how,
how you prepped, etc
Abbreviations - ANSAcceptable abbreviations are defined by the organization
Be consistent
Not using at this point of time
Health History - ANSDef: "structured framework for organizing patient information into verbal or
written form".
the pt's health story
focuses on essential information (what info do I need to address the particular situation of the
day ex. PCP may take several encounters, Urgent care- that particular concern of the day)
When it is comprehensive - can be very detailed - birth to early childhood to present day
Reasons do to a Health History - ANSfacilitates clinical reasoning
give you opportunity to organize thoughts and concerns to come up with a plan for the pt (what
tests to order or not, what physical exam do I need to do, what labs, what dx do I need to
consider)
*Listen to the pt they will tell you what exactly is wrong with them
Comprehensive History - ANS•Identifying information
•Source of history
•Chief Complaint/"Concern"
•History of Present Illness (what is happening right now (not the entire hx of the pt)
•Past Medical History
•Family History
•Personal and Social History
•Review of Symptoms
Comprehensive History: Identifying information - ANSidentifying data - pt's initials, age, gender
- Date and Time - keep a running detailed note
- Identifying Data: pt name and date of birth
, - Source of Information/Reliability - most pts will be their own source of info (they are awake,
alert and appropriate to give you this info) - others may have dementia or unconscious and
can't, have cognitive dysfunctions - document who is the source of information and how reliable
they are (pt can be a poor historian) - receive info from chart or other physicians - where this
info came from and how reliable this is
Comprehensive History: Source of history - ANSusually the pt but can be a family member,
caregiver, or friend, or the clinical record
Subjective Data - ANSIs what the patient tells you
includes symptoms and feelings, perceptions and concerns obtained from the clinical interview
usually verbal
ex. I think my heart is racing
Subjective Data: Documentation - ANSIncluded in CC, HPI, and ROS
Use patient's own words and quotes as appropriate
don't put in quotes the entire story. Use quotes if it is interesting or abnormal (ex. Feels like I am
swallowing razor blades)
Symptoms - ANShealth concerns that the pt tells you/complain of/they think or feel
ex. sore throat, HA, pain, feelings, perceptions, and concerns, cough
ex. I think my heart is racing, I have a HA, burning urination
Objective data - ANSis what you discover during the exam, tangible - can touch, can see it, can
test it
includes signs
all laboratory and diagnostic testing results, imaging, vitals
usually nonverbal - we see on the monitor and record it
ex. pt has tachycardia/irregular heart rate found on exam (after telling PA there heart is racing)
ex. pt has elevated WBC
Objective Data: Documentation - ANSIncluded in Vitals, Exam, Labs, and Imaging
Often in "check the box" form
May only include pertinent positives (- in review of systems)
ex. Doing an exam on an ankle - l ankle has edema, tenderness (don't mention they don't have
errythema)
signs - ANSis any objective evidence of a disease that can be observed by others (for example
a skin rash or lump)
ex. tenderness, edema, erythema
Comprehensive History: Chief Complaint/Concern (CC) - ANSprimary symptom or concern
causing the pt to seek care/prompts visit. may be one or two concerns/Sx or a short sentence
document in pt's own words
Documentation
Types of Medical Documentation (Notes) - ANSComprehensive History and Physical Exam Note
Focused History and Physical Exam Note
SOAP Note
Progress Note
Transition of Care Note
Procedure Note
Types of Medical Documentation (Notes): Comprehensive History and Physical Exam Note -
ANS-Need to know how to do all portions of this exam - includes a lot of things
-Will take you through everything
source of fundamental and personalized knowledge about the pt that strengthens the
clinician-patient relationship
-all the info about the pt, identifying info all the way through CC and HPI, PMH, Social Hx,
Exam, assessment/problem list, treatment plans/regular plans (sexual health, spiritual, etc) =
yearly physical - one time a year going through everything
Types of Medical Documentation (Notes): Focused History and Physical Exam Note -
ANShappen in urgent care/ER/pt family practice/internal medicine and follow up; pt seeking
care for specific concerns (ex. cough, painful urination), a more limited interview tailored to that
specific problem
- use in places at Urgent care, ER's or if you are following up with pt (pt you already know if
PCP and peds) - pt comes in with a specific concern - show up 3 months down the road bc they
have a new complaint (hurt ankle, sore throat)
Types of Medical Documentation (Notes): SOAP Note - ANSdocumentation: subjective,
objective, assessment, and plan - how the note is structured
-for follow up info or exam - pt comes in and has hypertension and see if medications have been
helping - CC, HPI and brief review of system (doesn't include F/S hx)
Types of Medical Documentation (Notes): Progress Note - ANSin patient/follow up visits -
addressing concern pt has - come back for a follow up visit
part of a medical record where healthcare professionals record details to document a patient's
clinical status or achievements during the course of a hospitalization or over the course of
outpatient care
- follow same format of SOAP - in patient notes - writing every day - add in a daily update as
whole hx isn't changing daily
,Types of Medical Documentation (Notes): Transition of Care Note - ANSpt needs to be
transitioned to different level of care ex. ICU to regular floor or from hospital to extended care
facility or DC summary that will be sent to PCP
- write when pt is transitioning level of care: pt is going out of the hospital (DC summary - note
sent to PCP/specialties), changing levels of care at the hospital - into or out of ICU - like SOAP
but also why they are able to move into or out of the hospital/ICU/hospital to extended care
facility/nursing home - person leaves your care you are writing a ___ Note - intake when they
come in and when they come out
Types of Medical Documentation (Notes): Procedure Note - ANSnote you write when you do a
procedure - what, why, and how
supplement to PN or History and Physical note - what procedure was done - what, why, how,
how you prepped, etc
Abbreviations - ANSAcceptable abbreviations are defined by the organization
Be consistent
Not using at this point of time
Health History - ANSDef: "structured framework for organizing patient information into verbal or
written form".
the pt's health story
focuses on essential information (what info do I need to address the particular situation of the
day ex. PCP may take several encounters, Urgent care- that particular concern of the day)
When it is comprehensive - can be very detailed - birth to early childhood to present day
Reasons do to a Health History - ANSfacilitates clinical reasoning
give you opportunity to organize thoughts and concerns to come up with a plan for the pt (what
tests to order or not, what physical exam do I need to do, what labs, what dx do I need to
consider)
*Listen to the pt they will tell you what exactly is wrong with them
Comprehensive History - ANS•Identifying information
•Source of history
•Chief Complaint/"Concern"
•History of Present Illness (what is happening right now (not the entire hx of the pt)
•Past Medical History
•Family History
•Personal and Social History
•Review of Symptoms
Comprehensive History: Identifying information - ANSidentifying data - pt's initials, age, gender
- Date and Time - keep a running detailed note
- Identifying Data: pt name and date of birth
, - Source of Information/Reliability - most pts will be their own source of info (they are awake,
alert and appropriate to give you this info) - others may have dementia or unconscious and
can't, have cognitive dysfunctions - document who is the source of information and how reliable
they are (pt can be a poor historian) - receive info from chart or other physicians - where this
info came from and how reliable this is
Comprehensive History: Source of history - ANSusually the pt but can be a family member,
caregiver, or friend, or the clinical record
Subjective Data - ANSIs what the patient tells you
includes symptoms and feelings, perceptions and concerns obtained from the clinical interview
usually verbal
ex. I think my heart is racing
Subjective Data: Documentation - ANSIncluded in CC, HPI, and ROS
Use patient's own words and quotes as appropriate
don't put in quotes the entire story. Use quotes if it is interesting or abnormal (ex. Feels like I am
swallowing razor blades)
Symptoms - ANShealth concerns that the pt tells you/complain of/they think or feel
ex. sore throat, HA, pain, feelings, perceptions, and concerns, cough
ex. I think my heart is racing, I have a HA, burning urination
Objective data - ANSis what you discover during the exam, tangible - can touch, can see it, can
test it
includes signs
all laboratory and diagnostic testing results, imaging, vitals
usually nonverbal - we see on the monitor and record it
ex. pt has tachycardia/irregular heart rate found on exam (after telling PA there heart is racing)
ex. pt has elevated WBC
Objective Data: Documentation - ANSIncluded in Vitals, Exam, Labs, and Imaging
Often in "check the box" form
May only include pertinent positives (- in review of systems)
ex. Doing an exam on an ankle - l ankle has edema, tenderness (don't mention they don't have
errythema)
signs - ANSis any objective evidence of a disease that can be observed by others (for example
a skin rash or lump)
ex. tenderness, edema, erythema
Comprehensive History: Chief Complaint/Concern (CC) - ANSprimary symptom or concern
causing the pt to seek care/prompts visit. may be one or two concerns/Sx or a short sentence
document in pt's own words
