Subjective data are the positive and negative pieces of information that the patient offers. Record the patient’s history, especially during an initial visit, to provide a comprehensive database. Arrange information appropriately in specific categories, usually in a particular sequence such as chronologic order with most recent information first. Include both positive and negative data that contribute to the assessment. Use the following organized sequence as a guide.
• List and describe current symptoms of chief concern and their appearance chronologically in reverse order, dating events and symptoms.
• List any expected symptoms that are absent.
• Identify anyone in household with same symptoms.
• Note pertinent information from review of systems, family history, and personal/social history along with findings.
• Where more than one problem is identified, address each in a separate paragraph, including the following details of symptom occurrence:
• Onset: when problem first started, chronologic order of events, setting and circumstances, manner of onset (sudden versus gradual)
• Location: exact location, localized or generalized, radiation patterns
• Duration: how long problem has lasted, intermittent or continuous, duration of each episode
• Character: nature of symptom
• Aggravating/associated factors: food, activity, rest, certain movements; nausea, vomiting, diarrhea, fever, chills, etc.
• Relieving factors: prescribed treatments and/or self-remedies, alternative or complementary therapies, their effect on the problem; food, rest, heat, ice, activity, position, etc.
• Temporal factors: frequency; relation to other symptoms, problems, functions; symptom improvement or worsening over time
• Severity of symptoms: quantify on a 0 (minimal) to 10 (severe) scale; effect on patient’s lifestyle
• List and describe each of the following with dates of occurrence and any specific information available:
• General health and strength over lifetime as patient perceives it; disabilities and functional limitations
• Hospitalization and/or surgery: dates, hospital, diagnosis, complications
• Adult illnesses and serious injuries
• Immunizations: polio, diphtheria-pertussis-tetanus, tetanus toxoid, haemophilus influenza type b, hepatitis A and B, measles, mumps, rubella, varicella, Prevnar, influenza, anthrax, smallpox, cholera, typhus, typhoid, meningococcal, pneumococcal, bacille Calmette-Guérin, last purified protein derivative or other skin tests, unusual reaction to immunizations
• Medications: past, current, recent medications (prescribed, nonprescription, complementary therapies, home remedies); dosages
• Allergies: drugs, foods, environmental
• Transfusions: reason, date, number of units transfused, reactions
• Emotional status: history of mood disorders, psychiatric attention or medications
• Recent laboratory tests (e.g., glucose, cholesterol, Pap smear, mammogram, prostate-specific antigen)
• Present information about age and health of family members in narrative or pedigree form, including at least three generations.
• Family members: Include parents, grandparents, aunts and uncles, siblings, spouse, children. For deceased family members, note age at time of death and cause, if known.
• Major health or genetic disorders: Include hypertension; cancer; cardiac, respiratory, kidney, or thyroid disorders; strokes; asthma or other allergic manifestations; blood dyscrasia; psychiatric difficulties; tuberculosis; diabetes mellitus; hepatitis; or other familial disorders. Note spontaneous abortions and stillbirths.
• Include information according to concerns of patient and influence of health problem on patient’s and family’s life:
• Cultural background and practices, birthplace, position in family
• Religious preference, religious or cultural proscriptions for medical care
• Home conditions: economic condition, number in household, pets, presence of smoke detectors, presence and security of firearms
• Occupation: work conditions and hours, physical or mental strain, protective devices used; exposure to chemicals, toxins, poisons, fumes, smoke, asbestos, or radioactive material at home or work
• Environment: home, school, work; structural barriers if handicapped, community services utilized; travel; exposure to contagious diseases
• Current health habits and/or risk factors: exercise; smoking; salt intake; weight control; dental hygiene diet, vitamins and other supplements; caffeine-containing beverages; alcohol or recreational drug use; response to CAGE, TACE, or RAFFT questions (see Appendix) related to alcohol use; participation in a drug or alcohol treatment program or support group
• Sexual activity: protection method, contraception
• General life satisfaction, hobbies, interests, sources of stress, adolescent’s response to HEEADSSS questions (see Appendix)
• Organize in general head-to-toe sequence, including an impression of each symptom.
• Record expected or negative findings as absence of symptoms or problems.
• When unexpected or positive findings are stated by patient, include details from further inquiry as you would in the present illness.
• Include the following categories of information (sequence may vary):
Objective data are the findings resulting from direct observation—what you see, hear, and touch.
• Color, integrity, temperature, hydration, tattoos, scars
• Presence of edema, excessive perspiration, unusual odor
• Presence and description of lesions (size, shape, location, inflammation, tenderness, induration, discharge), parasites
• Hair texture and distribution
• Nail configuration, color, texture, condition, presence of clubbing, nail plate adherence, firmness
• Visual acuity, visual fields
• Appearance of orbits, conjunctivae, sclerae, eyelids, eyebrows
• Pupillary shape, consensual response to light and accommodation, extraocular movements, corneal light reflex, cover–uncover test
• Ophthalmoscopic findings of cornea, lens, retina, optic disc, macula, retinal vessel size, caliber, and arteriovenous crossings
• Number, occlusion and condition of teeth; presence of dental appliances
• Lips, tongue, buccal and oral mucosa, floor of mouth (color, moisture, surface characteristics, ulcerations, induration, symmetry)
• Oropharynx, tonsils, palate (color, symmetry, exudate)
• Symmetry and movement of tongue, soft palate and uvula; gag reflex
• Respiratory rate, depth, regularity, quietness or ease of respiration
• Palpation findings: symmetry and quality of tactile fremitus, thoracic expansion
• Percussion findings: quality and symmetry of percussion notes, diaphragmatic excursion
• Auscultation findings: characteristics of breath sounds (pitch, duration, intensity, vesicular, bronchial, bronchovesicular), unexpected breath sounds
• Presence of friction rub, egophony, whispered pectoriloquy
• Anatomic location of apical impulse
• Heart rate, rhythm, amplitude, contour
• Palpation findings: pulsations, thrills, heaves, or lifts
• Auscultation findings: characteristics of S1 and S2 (location, intensity, pitch, timing, splitting, systole, diastole)
• Presence of murmurs, clicks, snaps, S3 or S4 (timing, location, radiation intensity, pitch, quality)
• Blood pressure: comparison between extremities with position change
• Jugular vein pulsations and distention, pressure measurement
• Presence of bruits over carotid, temporal, renal, and femoral arteries, abdominal aorta
• Pulses in distal extremities
• Temperature, color, hair distribution, skin texture, nail beds of lower extremities
• Presence of edema, swelling, vein distention, Homans sign, or tenderness of lower extremities
• Shape, contour, visible aorta pulsations, venous patterns, hernia
• Auscultation findings: bowel sounds in all quadrants, character
• Palpation findings: aorta, organs, feces, masses, location, size, contour, consistency, tenderness, muscle resistance
• Percussion findings: areas of different percussion notes, costovertebral angle tenderness
• Appearance of external genitalia and perineum, distribution of pubic hair, inflammation, excoriation, tenderness, scarring, discharge
• Internal examination findings: appearance of vaginal mucosa, cervix, discharge, odor, lesions
• Bimanual examination findings: size, position, tenderness of cervix, vaginal walls, uterus, adnexa, ovaries
• Posture: Alignment of extremities and spine, symmetry of body parts
• Symmetry of muscle mass, tone and muscle strength; grading of strength, fasciculations, spasms
• Range of motion, passive and active; presence of pain with movement
• Appearance of joints; presence of deformities, effusions, warmth, tenderness, or crepitus
The assessment section is composed of your interpretations and conclusions, their rationale, the diagnostic possibilities, and present and anticipated problems—what you think.
For each new and existing problem on the problem list, make a differential diagnosis list with rationale based on subjective and objective data. Describe disease progression or complication.