Lecture 2- The Medical Records

Chief Complaint (CC)

• why patient is seeking medical attention

• SUBJECTIVE

• in patient’s own words

• should be written in direct quotations

• does not get translated into medical terminology

• example: “i’ve had a bad sore throat for about a week”

History of Present Illness (HPI)

• patient interview with open ended questions

• chronological narrative of SUBJECTIVE complaints

• utilizes an “OPQRST” or “OLD CARTS”

• Starts with “This is a *** year old *** who presents with ***”

OPQRST

• O: onset

• P: provocation/ palliation

• Q: quality

• R: region & radiation

• S: severity

• T: time

OLD CARTS

• O: onset

• L: location

• D: duration

• C: character

• A: aggravating/ alleviating

• R: radiation

• T: time

• S: severity

Patient History

Facts of the patient’s history from the following categories:

• medical history: diseases/diagnoses with date diagnosed

• surgical history: procedure, location, date

• medications: prescription (dose, route, frequency) and over the counter/herbal supplements

• allergies: food, medication, environmental with reported reaction

• vaccinations: childhood, boosters, yearly, etc.

• social history: alcohol, smoking, illicit substances, occupation, living situation

• family history: cancer, heart disease, inheritable conditions, etc.

Review of Systems (ROS)

• SUBJECTIVE review of each body system

• highlights pertinent positive or negative responses surrounding current CC/HPI

• Body systems examples: general, neuro, head/ears/nose/throat, respiratory, cardiovascular, gastrointestinal, genitourinary, muscoskeletal

Vital Signs

• OBJECTIVE measurements

• includes: temperature, heart rate, blood pressure, respiratory rate, oxygenation

temperature (where to measure)

• vital sign

• reported in celcius or farenheit

• measured with thermometer in specific sites like:

  • oral- under tongue

  • axillary- armpit

  • rectal- rectum

normal adult temperature

• 37 degrees celcius

• 98.6 degrees fahrenheit

Hypothermia

condition of low temperature (<35 degrees C)

Normothermia

• condition of norma temperature

Hyperthermia

• condition of high temperature

• (>38 degrees C)

thermoregulation

maintenance of body temperature

heart rate + measurements

• reported in beats per minute

• pulse oximeter on distal

• electrocardiogram (ECG/EKG, can also assess rythym

• felt and counted by hand x1 minute at pulse sites if irregular rythym

• auscultated and counted x1 minute with stethoscope (apical pulse)

normal adult heart rate

60-100 BPM

tacycardia

fast heart rate, >100BPM

bradycardia

slow heart rate, <60BPM

arrhythmia/dysrhythmia

condition of abnormal heart rythym