S: Subjective
Information the patient or patient representative told you
Initials: T.J. Age: 28 Gender: Female
Heigh Weigh BP HR RR Temp SPO2 Pain Allergi
t t es
170 89kg 140/ 89 20 98.5 97% Medication: Penicillin - Rash
F
cm 81 Food: KNA
Environment: Dust – asthma exacerbation, runny
nose, watery eyes Cats – sneezing, itchy and
watery eyes, runny nose chest tightness,
wheezing
History of Present Illness (HPI)
Chief Complaint “breathing problems” CC is a BRIEF statement
(CC)
identifying why the patient
Onset 2 days ago
is here - in the patient’s own
Location Chest
words - for instance
Duration 5 minutes at the longest every 4 hours: 5 times a day
"headache", NOT "bad
Characteristics Wheezing, Chest tightness, difficulty breathing, cough
headache for 3 days”.
Aggravating Cat’s, dust, laying down at night, or increased physical
Factors activity Sometimes a patient has
Relieving Factors Drinking water helps cough, albuterol helps within 5 more than one complaint.
minutes For example: If the patient
, 2
Treatment Albuterol inhaler, 3 puffs every 4 hours presents with cough and
sore throat, identify which
is the CC and which may be
an associated symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or
homeopathic products.
Medication Length of
Dosag Frequency Time Reason for Use
(Rx, OTC, or e Used
Homeopathic)
Albuterol (Proventil) 90 mcg each puff 2-3 puffs Every four Chest tightness, or wheezing
inhaler hours due to
asthma
Tylenol Gel 500 mg 1 capsule Once a Headache
caps, extra week or
strength less
Advil 200 mg tablets 3- 200mg tablets First two For menstrual cramping
days of
menstrual
cycle
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, 3
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all
adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Diagnosed with Type 2 Diabetes at the age of 24. Non-compliant with diet
Immunizations up to date, Childhood vaccines current. Last Tetanus approximately one year ago. Last
Flu vaccine 5-6 years ago. Diagnosed with Asthma at the age of 2 and a half. Hospitalized for Asthma at
age 16,
Denies surgical history, broken bones, or recent hospitalizations.
Heavy Menstrual bleeding, with irregular cycles, mold breast
tenderness before cycle. Last PAP smear was four year ago.
Normal.
No recent dental exam, last dental visit was a few years ago, went
twice a week as a child. No recent eye exam. Last exam as a child.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and
alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
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