Medical record

  • From
  • CC:
  • HPI: Where, When, How, Why
  • Sleep, urine, stool, water intake,
  • CM: Name, dose, How long
  • PMH: 
    • DM/HTN/TB/Cancer/, 
    • Hospitalization
  • Past surgery: Cause, date
  • OBGYN: LMP, GPA,
  • FH: blood-relative disease like DM/HTN/cancer/TB...
  • PH: Stress
  • PE: 
    • GA
    • Eyes
    • throat
    • neck
    • GI
    • RS
    • CVS
    • Genitourinary
  • A
  • P


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Medical Chart

Patient's identification Date of Entrance:  ,Time:  ,ID: Department:  ,Room: Patient's name:  ,Sex:  ,Age: Nationality:  ,Occupation: Address: Referral from: Chief Complaint Main symptoms that the patient comes to see a doctor History of present illness(HPI) Location:  ,Severity:  ,Duration:   When Progressing, regressing, steady constant, intermittent, frequency aggravating, alleviating, Associated factor Medications Allergic  Currence medication(CM) Past of medical history(PMH) Medications/Vitamins/Herbal(-/-/-) Allergies Operations/Hospitalizations/Blood transfusions(-/-/-) When?How many?Type? Adult patient: DM/HTN/MI/Stroke/Peptic ulcer/Asthma/Emphysema/Thyroid/Liver/Kidney/ Bleeding/Cancer/TB/Hepatitis/STD ask about routine health maintenance Pediatric patient: Past Surgical and OBGYN history Past surgical history: Type, date, pathology OBGYN history(If female): Menarche, Menstrual cycle, Paragravida, abortion Urogenital tract:...
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