Documentation of a Patient Interview
What are all of the major parts to the documentation of a patient interview? (11 items) - ANS1.
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) - ANS1) Name
2) DOB
3) Age
4) Gender
5) Patient reliability
6) Use of an interpreter
4 Things to remember about documenting the chief complaint - ANS1) 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 - ANS1) 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? - ANSPatient'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 - ANSOnset
Location
Duration
Characteristics
Aggravating, Alleviating, Associated symptoms
Radiation
Temporal pattern
Severity
4 Questions to ask about Onset - ANS*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?
*Physical activity at onset:* What were you doing at onset? What was your emotional state?
* Location of patient at onset:* Where were you at onset?
5 Questions to ask about Location - ANS*Precise location:* Obtain price location of symptom
(ask patient to point)
*Migration:* Has the pain migrated/did it begin somewhere else?
*Localized/Diffuse:* Is it localized or diffuse?
*Deep/Superficial:* Is it deep or superficial?
*Radiation:* Does it radiate?
3 Questions to ask about Duration - ANS*Duration:* How long have the symptoms been
present?
*Consistent/Episodic:*Are the symptoms consistent or intermittent?
*Duration/Frequency of Episodes:* How long does it last/how often does it occur?
1 Question to ask about Characteristics and 9 Descriptors - ANS*Description of Sx:* What does
it feel like?
Sharp, stabbing, aching, burning, pressure, heaviness, tightness, tearing/ripping, tingly
3 Questions to ask about Aggravating/Alleviating/Associated Symptoms - ANS*Better/Worse:*
Does anything make the pain feel better/worse?
*Relieve/Reproduce:* What have you tried and did it work? Does anything completely relieve
your symptoms? What would be needed to reproduce your symptoms?
*Associated symptoms:* Are there any other symptoms that go along with this?
What are all of the major parts to the documentation of a patient interview? (11 items) - ANS1.
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) - ANS1) Name
2) DOB
3) Age
4) Gender
5) Patient reliability
6) Use of an interpreter
4 Things to remember about documenting the chief complaint - ANS1) 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 - ANS1) 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? - ANSPatient'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 - ANSOnset
Location
Duration
Characteristics
Aggravating, Alleviating, Associated symptoms
Radiation
Temporal pattern
Severity
4 Questions to ask about Onset - ANS*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?
*Physical activity at onset:* What were you doing at onset? What was your emotional state?
* Location of patient at onset:* Where were you at onset?
5 Questions to ask about Location - ANS*Precise location:* Obtain price location of symptom
(ask patient to point)
*Migration:* Has the pain migrated/did it begin somewhere else?
*Localized/Diffuse:* Is it localized or diffuse?
*Deep/Superficial:* Is it deep or superficial?
*Radiation:* Does it radiate?
3 Questions to ask about Duration - ANS*Duration:* How long have the symptoms been
present?
*Consistent/Episodic:*Are the symptoms consistent or intermittent?
*Duration/Frequency of Episodes:* How long does it last/how often does it occur?
1 Question to ask about Characteristics and 9 Descriptors - ANS*Description of Sx:* What does
it feel like?
Sharp, stabbing, aching, burning, pressure, heaviness, tightness, tearing/ripping, tingly
3 Questions to ask about Aggravating/Alleviating/Associated Symptoms - ANS*Better/Worse:*
Does anything make the pain feel better/worse?
*Relieve/Reproduce:* What have you tried and did it work? Does anything completely relieve
your symptoms? What would be needed to reproduce your symptoms?
*Associated symptoms:* Are there any other symptoms that go along with this?
