CHAPTER 22 Reporting and Recording
SUBJECTIVE DATA—THE HISTORY
Subjective data are the positive and negative pieces of information that the patient offers. Record the patient’s history, especially during an initial visit, to provide a comprehensive database. Arrange information appropriately in specific categories, usually in a particular sequence such as chronologic order with most recent information first. Include both positive and negative data that contribute to the assessment. Use the following organized sequence as a guide.
CHIEF CONCERN/PRESENTING PROBLEM/REASON FOR SEEKING CARE
Description of patient’s main reasons for seeking health care, in patient’s own words with quotation marks. Paraphrase only if this makes the patient’s concern more clear.
HISTORY OF PRESENT PROBLEM
List and describe current symptoms of chief concern and their appearance chronologically in reverse order, dating events and symptoms.
Note pertinent information from review of systems, family history, and personal/social history along with findings.
Where more than one problem is identified, address each in a separate paragraph, including the following details of symptom occurrence:
Onset: When problem first started, chronologic order of events, setting and circumstances, manner of onset (sudden versus gradual)
Aggravating/associated factors: Food, activity, rest, certain movements; nausea, vomiting, diarrhea, fever, chills, etc.
Relieving factors: Prescribed treatments and/or self-remedies, alternative or complementary therapies, their effect on the problem; food, rest, heat, ice, activity, position, etc.
Temporal factors: Frequency; relation to other symptoms, problems, functions; symptom improvement or worsening over time
MEDICAL HISTORY
List and describe each of the following with dates of occurrence and any specific information available:
General health and strength over lifetime as patient perceives it; disabilities and functional limitations
Immunizations: Polio, diphtheria-pertussis-tetanus, tetanus toxoid, hemophilus influenza type b, hepatitis A and B, measles, mumps, rubella, varicella, Prevnar, influenza, anthrax, smallpox, cholera, typhus, typhoid, meningococcal, pneumococcal, bacille Calmette-Guérin (BCG), last purified protein derivative (PPD) or other skin tests, unusual reaction to immunizations
Medications: Past, current, recent medications (prescribed, nonprescription, complementary therapies, home remedies); dosages
Family history
Present information about age and health of family members in narrative or pedigree form, including at least three generations.
Family members: Include parents, grandparents, aunts and uncles, siblings, spouse, children. For deceased family members, note age at time of death and cause, if known.
Major health or genetic disorders: Include hypertension; cancer; cardiac, respiratory, kidney, or thyroid disorders; strokes; asthma or other allergic manifestations; blood dyscrasia; psychiatric difficulties; tuberculosis; diabetes mellitus; hepatitis; or other familial disorders. Note spontaneous abortions and stillbirths.
PERSONAL/SOCIAL HISTORY
Include information according to concerns of patient and influence of health problem on patient’s and family’s life:
Home conditions: Economic condition, number in household, pets, presence of smoke detectors, presence and security of firearms
Occupation: Work conditions and hours, physical or mental strain, protective devices used; exposure to chemicals, toxins, poisons, fumes, smoke, asbestos, or radioactive material at home or work
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