2026 update
Demographic Information - ✔✔ANS Identifiers: name, address, phone number
gender, age
How many methods of ID should you use, and what should they be? - ✔✔AN
Two, name and date of birth
Chief Complaint (CC) - ✔✔ANS main reason for the visit
Subjective symptoms - ✔✔ANS patients own words/feelings that are no
measure
- pain, itching
How do you record subjective symptoms? - ✔✔ANS use quotation marks
Objective symptoms - ✔✔ANS can be measured and observed
- past medical history, vital signs
medical reconsiliation - ✔✔ANS compares patient list to medical record a
every visit, updates allergies
, administrative information - ✔✔ANS patient information/demographic
financial insurance information, correspondance
medical history - ✔✔ANS past illnesses, surgery, injuries
family history - ✔✔ANS illness/disease in immediate family
social history - ✔✔ANS diet, exercise, smoking/drugs, alcohol, habits
occupational history - ✔✔ANS employment hazars/exposures
screening/wellness assessments may include - ✔✔ANS - alcohol, tobacco
caffeine, drugs, substance intake
- sexual practices
- diet and exercise
- occupational/employment history
What do you do if a patient declines to answer questions? - ✔✔ANS Encourag
them, but if they refuse document "patient declined to answer"
Patient mental health questionnaire - 2 (PHQ-2) - ✔✔ANS patients frequency o
depressed mood over two weeks
Patient mental health questionnaire - 9 (PHQ-9) - ✔✔ANS if PHQ-2 answers
reflect positive response, asks additional questions