Current Clinical Strate-
gies
Family Medicine
Year 2004 Edition
Paul D. Chan, MD
Christopher R. Winkle, MD
Peter J. Winkle, MD
Current Clinical Strategies
Publishing
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Copyright © 2004 Current Clinical Strategies Publishing.
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Printed in USA
ISBN 1929622-36-8
INTERNAL MEDICINE
Medical Documentation
History and Physical Examination
Identifying Data: Patient's name; age, race, sex. List the
patient’s significant medical problems. Name of infor-
mant (patient, relative).
Chief Compliant: Reason given by patient for seeking
medical care and the duration of the symptom. List all
of the patients medical problems.
History of Present Illness (HPI): Describe the course of
the patient's illness, including when it began, character
of the symptoms, location where the symptoms began;
aggravating or alleviating factors; pertinent positives
and negatives. Describe past illnesses or surgeries,
and past diagnostic testing.
Past Medical History (PMH): Past diseases, surgeries,
hospitalizations; medical problems; history of diabetes,
hypertension, peptic ulcer disease, asthma, myocardial
infarction, cancer. In children