RR Temp SPO2 Pain
Rating
Allergies (and reaction)
170
cm
88 kg 139/
87
82 16 98.9 99% Medication: Penicillin (Rash/Hives)
Food: Denies
Environment: Cats (sneezing, eyes itch, runny nose, asthma
exasperation)
H
...
RR Temp SPO2 Pain
Rating
Allergies (and reaction)
170
cm
88 kg 139/
87
82 16 98.9 99% Medication: Penicillin (Rash/Hives)
Food: Denies
Environment: Cats (sneezing, eyes itch, runny nose, asthma
exasperation)
History of Present Illness (HPI)
Chief Complaint (CC) “After a fender bender 1 week ago I have had headaches and a sore neck.” CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - for instance
"headache", NOT "bad headache for 3
days”. Sometimes a patient has more
than one complaint. For example: If
the patient presents with cough and
sore throat, identify which is the CC
and which may be an associated
symptom
Onset 2 days after car accident
Location Head and neck
Duration Every day for 5 days
Characteristics Dull ache like a crown around the front and back of head
Aggravating Factors Movement
Relieving Factors Tylenol, rest, and decreased movement
Treatment Tylenol, rest, and decreased movement
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
Tylenol 325 mg x2 Every 4-6 hours As needed Headache and neck pain
Proventil 90 mcg 2 inhalations As needed Asthma exasperation
Ibuprofen 200 mg x3 Every 6-8 hours As needed Menstrual cramps
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
S: Subjective
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