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BRIEF HISTORY & PHYSICAL Patient Name: ___Date:___ DOB: ___Physician: ___ HISTORY OF PRESENT ILLNESS: ___ ___ MEDICAL/SURGICAL HISTORY: ___ ___ ___ ___ ___ ___ ___ALLERGIES: (medication and reaction)
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How to fill out history of present illness
How to fill out history of present illness
01
Begin by gathering information about the patient's chief complaint, including when it started, how it began, and any associated symptoms.
02
Document the patient's medical history, including any pre-existing conditions, surgeries, or medications they are currently taking.
03
Take note of any relevant family history, such as genetic conditions or illnesses that other family members have experienced.
04
Record the patient's social history, including their living situation, occupation, and any habits or lifestyle factors that may be impacting their health.
05
Document any allergies the patient has, as well as their vaccination history and any recent travel or exposures to infectious diseases.
Who needs history of present illness?
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Physicians
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Nurses
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Medical students
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Other healthcare providers
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What is history of present illness?
The history of present illness (HPI) is a detailed account of the symptoms and issues that led to the patient's current healthcare visit, focusing on the chronological narrative of the patient's medical condition.
Who is required to file history of present illness?
Healthcare providers, such as physicians and nurse practitioners, are required to 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 HPI, document the patient's symptoms, duration, severity, location, contextual information, and any previous treatments related to the current complaint in a structured narrative format.
What is the purpose of history of present illness?
The purpose of HPI is to provide a comprehensive understanding of the patient's current health issue, which helps guide diagnosis and treatment planning.
What information must be reported on history of present illness?
HPI must report details such as the onset of symptoms, their duration, specific characteristics, any aggravating or relieving factors, and associated symptoms.
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