Contents of a Medical Chart
Clinical Pharmacy
3E-PH
First Shifting
August 10, 2020
Reviewer 1
Surname 1, Surname 2, Surname 3, Surname 4 [Editor’s Surname]
1 of 4
Medical Chart
• a narrative or record of past events and circumstances that are or
may be relevant to a patient's current state of health.
• a comprehensive statement of facts pertaining to past and
present health gathered, ideally from the patient
Contents of a Medical Chart
1. Admission Report
2. Consent to Treatment Statements
3. Attestation Statement (Attending Physician's Statement)
4. Medical History
5. Physician's Orders
6. Report of Physical Examination
7. Progress Notes
8. Pathology Reports
9. Radiology Reports
10. Consultation Reports
11. Anesthesia Record
12. Operative Report
13. Nurses’ Notes
14. Vital Signs Graphics
15. Medication and Administration Record
16. Laboratory Report
17. Physical Therapy Evaluation
18. Respiratory Therapy Evaluation
19. Special Reports (Obstetrics, Nursery)
20. Discharge Reports
Medical History
A. Patient Demographics
• Patient Name
• Age
• Gender
• Status
• Address
• Occupation
• Religion
B. Chief Complaint (CC)
• Indicate the reason of admission to the hospital in the words of
the informant
• EXAMPLE:
− “I’m having pain in my leg.”
− “I was not feeling well, and I think I passed out.”
− “My right arm feels like it’s frozen. I can barely move it.”
C. History of Present illness (HPI)
• A chronologic description o f the development of the Pt's present
illness
• EXAMPLE #1: Carson Johnson is a 67-year-old African-
American man admitted in the emergency room at 8:45 AM after
noticing a sudden onset of weakness in his right arm. He woke
up at 7:15 AM and went to the bathroom to brush his teeth. While
walking from the bathroom to the kitchen, h e noticed general
weakness and had trouble saying “good morning” to his son, with
whom he lives. His son immediately brought him to the ER. While
in the ER, he started to have a rightsided facial drop. He denied
any dizziness, vomiting, or headache.
• EXAMPLE # 2: This is the first admission for this 13-month-old
white boy who was felt to be well until approximately 3 weeks ago
when his stools became loose and f requent. This problem
persisted with three to four stools daily until three days ago when
he developed a fever (documented only by his mother's feeling
that he was warm). The stools became green and "slimy"
although the frequency remained unchanged. His intake of fluids
consisted of three 3-oz. bottles of whole milk. No solids were
tolerated. On the day of admission the baby did not take any
feedings. He vomited twice admitted to the hospital. No fever was
noted. His responsiveness had decreased to the point of
unresponsiveness. On arrival in the e mergency room he was
immediately given an intravenous bolus of normal saline and
admitted to the ward.
D. Past Medical History
• Prior illnesses
• Past treatments
• All medical and surgical hospitalization
• EXAMPLE#1: In 1996, Lucy experienced a minor stroke, which
caused temporary paralysis in her left arm. She was monitored in
hospital for three weeks and recovered. 3 years ago, Lucy was
diagnosed as lupus carrier. Since the diagnosis, Lucy has been
taking Warfarin and she expects to maintain Warfarin therapy fo r
life.
• EXAMPLE #2: Hypertension. He appears to have had this for at
least the last fifteen years. Reviewing his outpatient records his
blood pressures average in the upper 140s for systolic pressures
and 70s for diastolic pressures, consistent with isolated systolic
hypertension. He is on Atacand and Lopressor. His last EKG was
in November 2007 and showed no chamber enlargement by ekg
criteria. He does show evidence of hypertensive heart disease on
his last echo in November 2 007 with concentric left ventricular
hypertrophy.
• EXAMPLE #3:
− Hypertension
− Dyslipidemia
− s/p appendectomy 2009
− s/p CABG in 2007
− s/p cataract surgery in 2011
− s/p kidney stone retrieval 2013
E. Family Medical History
• present health or cause of death of parents, brothers, sisters
F. Social History
• Marital status
• Past and present occupations
• Travel
• Hobbies
• Stresses
• Diet
• Habits
• Use of tobacco, alcohol, or drugs
G. Medication, Allergies and Immunization
• List any medications prescription, including over-the-counter
medications, home remedies, vitamins, and supplements as well.
H. Review of System
• An organized and complete examination of a Pt's organ systems
• Includes the patient’s “inventory” of signs and/or symptoms.
These are most ofte n answer to questions asked by the provi der
in order to establish a working diagnosis.
• QUESTIONS:
− “Do you have any problems breathing?”
− “Do you have shortness of breath when exercising, walking,
climbing the stairs?”
• TRANSCRIPTIONS:
− Patient states his chest hurts when he coughs, but not when he
takes a deep breath.
− “No SOB”
− “No complaints of pain in joints”
− “No problems sleeping.”
