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Documentation Strategies
This is an example of how pertinent ROS are included in the HPI of a comprehensive history and physical. The second note is a focused note written as a follow-up to the first comprehensive note. POLDCARTS are color-coded to demonstrate how to word the note.
First Visit with Complete H & P (only selected info is included here)
CHIEF COMPLAINT (CC): New onset chest pain
HISTORY OF PRESENT ILLNESS (HPI)
[S] Slim, a 45 y/o c/o of sudden onset of intermittent left sided pressure-like, non-radiating chest pain for the past 24 hours that seems to be aggravated by activity (mowing lawn) and relieved by 5 minutes of rest. It starts as a gradual ache and he rates it as 8/10 at its worst. This occurred a few weeks ago when he was working out at the gym lifting weights. The discomfort has never occurred without preceding activity. Denies diaphoresis, back pain associated with activity, nausea, SOB, edema, symptoms of GERD, pleuritic chest pain, prior anxiety and history of HTN, heart murmur, hyperlipidemia, asthma, or problems with sexual dysfunction. [This is part of ROS that is pertinent to understanding the HPI.]
POLDCARTS
1PPrevious, Similar Occurrence; (Precipitating Factors) 2OOnset3LLocation4DDuration5CCharacteristics6AAggravating7RRelieving8TTemporal9SSeverity
PAST MEDICAL HISTORY (PMH)
MEDICATIONS
SOCIAL HISTORY (SH)
IMMUNIZATIONS & TRAVEL
ALLERGIES
ROS can leave out what is [in blue] since you included it in HPI
General health: Pts perception of current state of health.
HEENT: Denies headache, diplopia, blurred vision, eye pain or redness, cataracts, glaucoma, loss of visual field, hearing loss, tinnitus, vertigo, sinusitis, postnasal drip, nasal polyps, epistaxis, teeth/gums, oral cavity ulcers/growths, sore throat, hoarseness, glasses, contacts, dentures.
Pulmon: Denies cough, sputum, hemoptysis, [dyspnea, pleuritic chest pain], wheezing, [asthma], recurrent infections - bronchitis or pneumonia, occupational exposures (asbestos, pneumonoconiosis), sleep pattern.
Cardiovascular: See HPI. [chest pain or pressure], palpitations, orthopnea, PND, [SOB, pedal edema, heart murmur, HTN, hyperlipidemia], MVP, Hx rheumatic fever, phlebitis, varicose veins, claudication, cramping, Raynauds.
GI: Denies wt gain/loss, nausea, vomiting, diarrhea, constipation, hematemesis, melena, BRBPR, change in stool caliber, hemorrhoids, hepatitis, PUD, GB dysphagia, [GERD], belching or flatus, abd pain; pain radiation, what improves or increases pain, change in appetite, hernia.
GU: Denies dysuria, hematuria, nocturia, frequency, polyuria, decreased force of urination, hesitancy, incontinence, nephrolithiasis, UTIs, pyelonephritis.
Male: Denies hernia, testicular masses or pain, penile discharge, penile sores, prostatitis, [sexual dysfunction], STDs.
Neuro: Denies dizziness, syncope, seizures, vertigo, paresthesias, weakness, tremor, memory disturbance.
Rheum: Denies arthritis, joint stiffness or swelling, myalgias, gout lyme disease, back pain.
Heme: Denies anemia, ease of bruising or bleeding, prior transfusions & reactions, blood type, lymph node enlargement, pain; fatigue, fever, chills, night sweats.
Derm: Denies rashes, changes in moles or pigmentation, birthmarks, skin dryness, pruritus, lumps, changes in hair or nails.
Psych: Denies depression, agitation, [panic/anxiety], manic episodes, personality changes, hallucinations.
Endo: Denies temperature intolerance, polyuria, polydipsia, polyphagia
O Physical Exam (PE)
You would do a complete PE, but what is your working diagnosis? Be sure to document findings that will help rule in or rule out these diagnoses.
BP 154/98, P 92, R 12 T 98 Ht 6 Wt 290 BMI - 39
BP is this HTN or is he just anxious? Recheck it!
ENT - Retinal exam vascular changes
CV - heart listen for murmurs, S4, S3, pericardial rub; carotid bruit,
peripheral pulses, edema
Pulm listen for crackles, friction rub over left side of chest, wheezing
Abdomen aortic, renal, or iliac bruit; epigastric tenderness
MSK chest wall tenderness
A Chest pain of unknown etiology
Elevated BP
Obesity
P The Plan is not part of this course and will not be included in your write-ups. It is included here for demonstration purposes only.
EKG now
Stress test with cardiology ASAP
Fasting lipids, CBC, T4, TSH, CMP, u/a tomorrow
NTG 1/150 sl prn CP, take 1 sl q 5 minutes until CP gone. If not gone after 3rd dose, call 911. Do not drive to the hospital.
After stress test complete, start Atenolol 50mq qd
No exercise until after evaluation is complete
Follow-up after stress test or to ER if symptoms worsen or chest pain does not go away with rest and/or NTG x 3
Follow-up note when this patient returns.
What to include in f/u note
What you should assessResultsIn the history:Medications started
Side effects
Therapeutic effects/Effect on symptoms
Compliance
Denies
Improved, unchanged, worse
Did pt take as prescribed? Why? Why not?Symptoms;
Status of CC
Any new symptoms or worsening of previous ones?Denies
Improved, unchanged, worse
If new symptoms, go through POLDCARTS with themIn the exam:Pertinent systems onlyFollow-up focused note:
S Slim returns with no complaints of chest pain and has not taken NTG. Has not exercised since last visit, but wants to start again. Was told stress test normal and has started on atenolol, which he is tolerating well accept for some fatigue. Denies lightheadedness, syncope, dizziness, DOE, & wheezing. Admits to learning that a close friend who is younger than the pt died of a heart attack 2 days prior to last visit, and pt was worried that he had heart disease.
BP 134/78, P 62, R 12 T 98 Ht 6 Wt - 280
O Heart assess rate since on beta-blocker, recheck BP
Lung check for wheezes since beta-blockers can aggravate reactive airway disease, asthma.
Laboratory results list pertinent negatives and positives here
A Non-cardiac chest pain with anxiety component due to friends recent, untimely death from cardiac disease.
Elevated BP or call it HTN if has other objective signs of the disease
Morbid obesity has lost 10 pounds past week
Or,
S Slim, a 45 y/o male, is brought to the ER by the paramedics after having taken 3 NTG without relief of sudden onset, crushing, left-sided chest pain that radiated to his jaw and neck. The pain began 2 hours prior to admission while he was walking his dog. He was seen by his PCP 10 days ago with a CC of non-radiating left-sided chest pain. He had a normal stress test last week in a cardiologists office. The patient was given a prescription of atenolol 50mg from his PCP for elevated blood pressure, which he started after the stress test. However, he stopped it three days later due to fatigue. Denies lightheadedness, syncope, dizziness, DOE, wheezing, cough, PND, &. edema. FH/SH non-contributory.
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