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.
Record data recommended by health care facility.
Identification number/social security number
Address (home and business)
Insurance plan, number
Date of visit
For children and dependent adults, names of parents or next of kin
Put identifying information on each page of record.
SOURCE AND RELIABILITY OF INFORMATION
Document who is providing the history and relationship to patient.
Indicate when an old record is used.
State judgment about reliability of information.
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.
Include duration of problem.
HISTORY OF PRESENT PROBLEM
List and describe current symptoms of chief concern and their appearance chronologically in reverse order, dating events and symptoms.
List any expected symptoms that are absent.
Identify anyone in household with same 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)
Location: Exact location, localized or generalized, radiation patterns
Duration: How long problem has lasted, intermittent or continuous, duration of each episode
Character: Nature of symptom
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
Severity of symptoms: Quantify on a 0 (minimal) to 10 (severe) scale; effect on patient’s lifestyle
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
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.
Include information according to concerns of patient and influence of health problem on patient’s and family’s life:
Cultural background and practices, birthplace, position in family
Religious preference, religious or cultural proscriptions for medical care
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