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| History and Physical - documentation of patient history and physical examination findings |
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| History - record of subjective information regarding the patient's personal medical history, including past injuries, illnesses, operations, defects, and habits |
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| information obtained from the patient including his or her personal perceptions |
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| Complains Of - patient's description of what brought him or her to the doctor or hospital; it is usually brief and is often documented in the patient's own words indicated with quotes |
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| History of Present Illness (Present Illness) - amplification of the chief complaint recording details of the duration and severity of the condition (how long the patient has had the complaint and how bad it is) |
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| Symptom - subjective evidence (from the patient) that indicates an abnormality |
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| Past Medical History (Past History) - a record of information about the patient's past illnesses starting with childhood, including surgical operations, injuries, physical defects, medications, and allergies |
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| Usual Childhood Diseases - an abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood |
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| Family History -state of health of immediate family members |
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| Social History - a record of the patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol |
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| Occupational History - a record of work habits that may involve work-related risks |
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| Review Of Systems (Systems Review) 0 a documentation of the patient's response to questions organized by a head-to-toe review of the functions of all body systems |
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| facts and observations noted |
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| Physical Examination - documentation of a physical examination of a patient, including notations of positive and negative objective findings |
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| Head, Eyes, Ears, Nose, Throat |
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| No Acute Distress, No Appreciable Disease |
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| Pupils Equal, Round, and Reactive to Light and Accommodation |
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| Assessment - identification of a disease or condition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests and diagnostic procedures |
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| Rule Out - used to indicate a differential diagnosis when one or more diagnoses are suspect; each possible diagnosis is outlined and either verified or eliminated after further testing is performed |
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| Plan (also referred to as recommendation or disposition) - outline of the treatment plan designed to remedy the patient's condition, which includes instructions to the patient, orders for medications, diagnostic tests, or therapies |
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