The medical record is an important part of
the patient’s care in the clinic or
The information a scribe records on the
chart could affect how the patient is
managed currently or in the future.
To communicate relevant information to
other medical personnel.
It is a legal document that can be
presented in a court of law.
A physician may be asked to testify in
◦ Child abuse
◦ Civil procedures involving personal injury
The method used in charting the patient’s
stay through the clinic/ED must follow a
The most common method is to consider
the chart to have four generalized
The Subjective portion includes:
◦ Chief Complaint (CC)
◦ History of Present Illness (HPI)
◦ Review of Systems (ROS)
◦ Past Medical History (PMHx)
◦ Family History (FHx)
◦ Social History (SHx)
The Subjective section pertains to any
information that the patient and/or family
This information is dependent upon the
patient’s condition, beliefs, personality, etc.
This section will contain the patient’s story
in his/her own words.
◦ The main reason the patient has come to
◦ Every chart must have a Chief
◦ A short statement in the first sentence of
the HPI identifying why the patient has
come to the clinic/ED.
◦ Should be in the patient’s own words (if
History of Present Illness (HPI)
◦ Explains the Chief Complaint.
◦ Describes why the patient is in the
clinic/ED and lists any pertinent positives
◦ This should be in a narrative paragraph
consisting of 4-5 sentences depending
on the severity of the patient’s condition.
◦ The HPI is a chronological description of
the development of the patient’s present
illness from the first sign/symptom or
from the previous encounter to the
8 dimensions of HPI - directly related to
◦ Modifying factors
◦ Associated signs and symptoms
◦ A place on the body
Examples: R flank, midsternal chest, etc.
◦ Description of the complaint
Constant, dull, crampy, intermittent, etc.
◦ How bad is it?
◦ Usually on a scale of 1 to 10
Examples: Acute, mild/moderate/severe, 7/10, 3
pads in the last hour, etc.
◦ How long do the episodes last?
Examples: 30 seconds each, 5 years, etc.
◦ When did it start?
Examples: 3:00 AM, this afternoon, etc.
◦ What were you doing when it happened?
Examples: Running laps, just ate 7
doughnuts, awoken from sleep, etc.
◦ What makes it better or worse?
Examples: Worse with activity, improve
with nitroglycerin, increased pain with
Associated signs and symptoms
◦ Any other symptoms
Examples: If CC is chest
pain, associated with diaphoresis and
A review of the patient’s past medical,
social history, and family medical history.
Depending on the circumstances or
encounter, the patient’s Chief Complaint
could be an indication of a complication of,
or a result of, a preexisting condition or the
patient’s past medical history.
Past Medical History (PMHx)
◦ Includes injuries, chronic illnesses, and
Social History (SHx)
◦ Identifies behavioral risks such as
tobacco alcohol, or drug use.
Family History (FHx)
◦ Includes relevant past family medical
Past Medical History (PMHx)
◦ Hypertension (HTN), coronary artery disease
(CAD), chronic obstructive pulmonary disease
(COPD), diabetes (DM), coronary artery bypass graft
(CABG), cancer (Ca).
Past Surgical History
◦ A subcategory under PMHx.
Social History (SHx)
◦ Tobacco use (Tob), alcohol use (EtOH), intravenous
drug use (IVDA), living situation (lives alone, lives with
others, nursing home, or lives at home with parents).
Family History (FHx)
◦ Includes genetic traits, DM, Ca, cardiac disease, etc.
Review of Systems
Identifies any recent
patient may have
other than the
A Review of Systems is an inventory of
body systems obtained through a series of
questions seeking to identify signs and/or
symptoms which the patient may be
experiencing or has experienced.
◦ e.g. diaphoresis, cold symptoms, fever, chills.
◦ e.g. Visual changes, blindness, ophthalmoplegia, blurry, eye
Ear, Nose, Throat, Mouth
◦ e.g. dysphagia, tinnitus, epistaxis, rhinorrhea.
◦ e.g. palpitations, edema, cyanosis, dyspnea on exertion, CP.
◦ e.g. SOB/dyspnea, wheezing, cough.
◦ e.g. dysmenorrhea, dyspareunia, dysuria, vaginal bleeding.
◦ e.g. arthralgia, myalgia.
◦ e.g. rashes, hives, discoloration, pallor,
◦ e.g. H/A, dizziness, LOC, numbness,
◦ e.g. suicidal, depressed.
◦ e.g. cold intolerance, heat intolerance,
◦ If a patient is unable to provide any information
due to severity of illness, inebriation, intubation,
unconscious, etc., you may check the “Unable to
obtain HPI/ROS/PMFHSH secondary to pt’s
◦ Be careful when using this caveat, and only use it
if it really applies (HPI, Past Medical/Social/Family
History, and ROS only).
◦ Ask the physician for clarification when needed.
◦ Speaking another language is not an exception.
◦ Physical exam must be documented.
The Objective portion includes:
The Objective section contains
information that is obtained through
observation and testing and is
independent of an individual’s
Physical Examination (PEx)
◦ Information is more medically-oriented
◦ Information elicited through observation,
palpitation, percussion, and auscultation.
Medical Decision Making (MDM)
◦ Documented under “Progress Notes” and
contains Differential Diagnosis, Progress
notes, attending note.
Differential Diagnosis (DDx)
◦ Lists the different conditions that testing
will rule out.
◦ Any new subjective information provided
by the patient and any new or changed
findings upon reexamination of the
Re-eval at 1532 – Pt states she is improved. Nausea resolved. PEx: Abd
soft, NT/ND, nl active BS. Pt will be discharged and f/u with PMD advised
within 24 hours.
◦ Recorded when a physician oversees a
◦ This will follow the SOAP format.
A) Attending Note: Reviewed and agree c Hx.
B) PEx – GI: abd soft, NT, CVS: RRR s MGR. RESP: Lungs CTA.
C) A: UTI vs. Kidney stone
D) P: Labs, CT abd/pelvis r/o stone
the patient after
The Plan consists of:
◦ How the physician manages the patient’s
care after the final diagnosis has been
identified and can include:
◦ Ensure that the chart has been coded to
the appropriate level and enter
◦ Lists the various treatments, medications
Level 1: Visits requiring very minor care.
This level is seldom used in the ED but
would be used in a clinic setting.
◦ Removal of sutures from a well-healed, uncomplicated laceration.
◦ Tetanus toxoid immunization; Depo-Provera injection; hormone
◦ Several uncomplicated insect bites.
Level 2: Diagnosis reached without the aid
of any labs or x-rays.
◦ Painful sunburn with blister formation on the back in an otherwise
◦ Child presenting with impetigo localized to the face.
◦ Minor traumatic injury of an extremity with localized pain, swelling,
◦ Red, swollen cystic lesion on patient’s back in an otherwise
Level 3: Visits requiring minor lab work such as
CBC, U/A, or a few x-rays.
◦ Well-appearing child who has a fever, diarrhea, and
abdominal cramps and is tolerating oral fluid.
◦ Inversion ankle injury, patient is unable to bear weight on
the injured foot and ankle.
◦ Acute pain associated with a suspected foreign body in the
◦ Blunt head injury with local swelling and bruising without
subsequent confusion, loss of consciousness, or memory
deficit in an otherwise young and healthy adult.
Level 4: Visits requiring extensive lab workup or CT
◦ Child sustaining a head injury (falling off bicycle) with brief
loss of consciousness.
Level 5: Visits requiring admission into the
hospital, critical care patients.
◦ Complicated overdose requiring aggressive management to
prevent side effects from the ingested materials.
◦ New onset of palpitations/tachycardia requiring IV drugs.
◦ Active upper gastrointestinal bleeding.
◦ Motor vehicle accident with intraabdominal injuries or
multiple extremity injuries.
◦ Acute onset of chest pain compatible with symptoms of
cardiac ischemia and/or pulmonary embolus.
◦ Sudden onset of “the worst headache of my life” with
associated meningismus, nausea, and vomiting.
◦ New onset of a cerebral vascular accident.
◦ Acute febrile illness in an adult, associated with shortness of
breath and an altered level of alertness.