Practice Management Book

History

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Encounter History

Aka: Encounter History, PQRST Mnemonic
  1. See Also
    1. Review of Systems
    2. E/M History Criteria
    3. Medical Documentation
  2. History: Chief Complaint
    1. Reason for the encounter
  3. History: Present Illness (HPI)
    1. Components (8 HPI elements)
      1. Location
      2. Severity
      3. Timing
      4. Modifying factors
      5. Quality
      6. Duration
      7. Context
      8. Associated signs and symptoms
    2. Mnemonic: PQRST (plus context and associated factors)
      1. Palliative and Provocative (modifying factors)
      2. Quality
      3. Region and Radiation (location)
      4. Severity
      5. Timing (and duration)
  4. History: Past Medical
    1. Current medications
    2. Drug allergies
    3. Prior surgeries
    4. Prior hospitalizations
    5. Prior major illnesses or injuries
    6. Immunizations
  5. History: Family
    1. Health status or cause of death of near relatives
      1. Parents
      2. Siblings
      3. Childrens
    2. Specific disease related to CC, HPI, ROS
    3. Hereditary Diseases for which the patient is at risk
  6. History: Social
    1. Occupational history
    2. Current employment
    3. Level of education
    4. Marital status or living arrangements
    5. Sexual history
    6. Habits
      1. Nutritional status
      2. Tobacco use
      3. Alcohol use
      4. Illicit Drug use
  7. History: Review of Systems (14 systems)
    1. See Review of Systems
    2. Constitutional
    3. Eyes
    4. Ears, nose, mouth, throat
    5. Cardiovascular
    6. Respiratory
    7. Gastrointestinal
    8. Genitourinary
    9. Musculoskeletal
    10. Skin (integument, includes Breast)
    11. Neurologic
    12. Psychiatric
    13. Endocrine
    14. Hematologic or Lymphatic
    15. Allergic or immunologic
  8. Exam (12 systems)
    1. Constitutional
    2. Eyes
    3. Ears, Nose, Throat
    4. Cardiovascular
    5. Respiratory
    6. Gastrointestinal
    7. Genitourinary
    8. Musculoskeletal
    9. Skin (integument, includes Breasts)
    10. Neurologic
    11. Psychiatric
    12. Hematologic or Lymphatic

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