Chief Complaint
Finding:
Established chief complaint
Finding:
Reports pain
( )
Pro Tip: Beginning your conversation with your patient by asking an
... [Show More] open-ended question
about their hospital visit is a best practice for gauging your patient's general condition.
Example Question:
What brings you to the hospital?
Finding:
Reports blood in urine
( )
Pro Tip: Beginning your conversation with your patient by asking an open-ended question
about their symptoms is a best practice for gauging your patient's general condition.
Example Question:
What are your symptoms?
Finding:
Reports increased frequency of urination
( )
Pro Tip: A patient with flank pain and blood in urine may have kidney stones, a bladder
infection, or another serious complaint that may affect urinary patterns.
Example Question:
Have you had urinary symptoms?
Orientation
Finding:
Asked about orientation
Finding:
Oriented to own person
(Available)
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to state their name so you can determine their cognitive
functioning.
Example Question:
Can you tell me who you are?
Finding:
Oriented to place
(Available)
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to identify where they are so you can determine their cognitive
functioning.
Example Question:
Do you know where you are right now?
Finding:
Oriented to situation
( )
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to identify their reason for being here so you can determine their
cognitive functioning.
Example Question:
Do you know why you are here today?
Finding:
Oriented to time
(Available)
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to identify the date and year so you can determine their cognitive
functioning.
Example Question:
What is the date and year?
History of Present Illness
Finding:
Asked about onset and duration of symptoms
Finding:
Reports pain began 3 days ago
( )
Pro Tip: Discovering how long ago the pain began is the first step in understanding whether
the pain is chronic or acute.
Example Question:
When did your pain begin? [Show Less]