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UM Clinical Medicine Course
Shadowing Template (Core)Student:
Yes
No
HISTORY :Renovate:
Commentaries elements of History Documented?
Chief Complaint:
Onset:
Duration:
Location:Radiation:
Intensity:
Quality:
Aggravating
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How to fill out history of present illness
How to fill out history of present illness
01
To fill out the history of present illness, follow these steps:
1. Start by gathering relevant information about the patient's current health condition.
2. Begin by documenting the chief complaint, which is the main reason for the visit or consultation.
3. Provide a detailed account of the patient's symptoms, including the onset, duration, and severity.
4. Include any relevant medical history and pre-existing conditions that may be contributing to the current illness.
5. Document any treatments or interventions the patient has already received for their condition.
6. Ask the patient about any changes in their symptoms or any factors that may worsen or alleviate their symptoms.
7. Record any physical examinations or diagnostic tests that have been performed to assess the patient's condition.
8. Summarize the patient's current health status and their response to previous treatments.
9. Include any relevant information about the patient's lifestyle or environmental factors that may be influencing their illness.
10. Use clear, concise language and avoid unnecessary medical jargon.
02
Remember to update the history of present illness as new information becomes available or as the patient's condition changes.
Who needs history of present illness?
01
The history of present illness is essential for healthcare professionals, including doctors, nurses, and other clinicians. It helps them understand the patient's current health status, gather important information for diagnosis and treatment planning, and track the progress of the illness over time.
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What is history of present illness?
The history of present illness (HPI) is a detailed account of the patient's current medical issue, including the onset, duration, characteristics, and any associated symptoms. It provides context for the chief complaint.
Who is required to file history of present illness?
Healthcare providers, especially those involved in patient care such as physicians, nurse practitioners, and physician assistants, are required to document and file the history of present illness as part of the patient's medical record.
How to fill out history of present illness?
To fill out the history of present illness, a clinician should gather information from the patient regarding the current symptoms, including when they started, their nature, severity, location, and any aggravating or relieving factors. This information is then documented in a clear and organized manner.
What is the purpose of history of present illness?
The purpose of the history of present illness is to provide a comprehensive understanding of the patient's current medical condition, facilitate diagnosis, guide treatment decisions, and document the clinical course of the illness.
What information must be reported on history of present illness?
The HPI must report patient's symptoms, duration, severity, timing, context, modifying factors, and any relevant medical history that connects to the current health issue.
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