The components, and why they are separate
Assign lines to components, then press Check my filing.
Write the words, not the label. The reason for seeking care is a brief statement, ideally in the patient’s own quoted words, plus a duration: “‘My heart’s been flip-flopping since Saturday’ — 3 days,” not “atrial fibrillation.” The patient’s words are data; your diagnostic label is inference, and inference belongs later. Recording a label instead of the words quietly closes the differential before anyone has examined the patient.
Occupation is not administrative trivia. A forty-year history of grain dust, asbestos or solvent exposure explains a chest film, and a night-shift schedule explains a haemoglobin A1c. It is filed under biographic data and it is read as risk.
Source and reliability
Record who provided the information — the patient is the
primary source; a parent, spouse, group-home staff member, prior record or EMS report is a
secondary source. Then state whether the account seems reliable, and why. Reliability is not an insult; it is a flag for whoever reads your note next.
What she is actually taking
—of 8 medications found
Tick your questions, then press Take the history.
Patients almost never volunteer drops, topicals or supplements when asked “what medications do you take?” — because in their mind those are not medications. Ask about each category explicitly: prescriptions, over-the-counter products, vitamins, herbal supplements, inhalers, eye drops, patches, injectables and “as needed” medicines. For each, capture drug, dose, route, frequency, indication, and when the last dose was actually taken, which is often not what the label says.
Allergy, intolerance, or unusable
Classify each entry, then press Check my reading.
“Allergic to penicillin” is nearly useless. “Penicillin — hives and lip swelling within 1 hour, age 22, required epinephrine” is actionable. “Penicillin — upset stomach as a child” describes an intolerance, not an allergy. That distinction changes antibiotic choice and patient outcomes — patients labelled penicillin-allergic on the basis of childhood nausea receive broader, more toxic and less effective alternatives for the rest of their lives.
Ask separately about
Food · latex · contrast media · tape and adhesives · environmental allergens. Document the
reaction, the timing, the severity, the date and what treatment was required.
Three generations, and the age at diagnosis
Make your calls, then press Check my calls.
Age at diagnosis is the whole game. A father with a myocardial infarction at 78 is unremarkable; a father with a myocardial infarction at 44 is a premature-family-history risk factor that changes lipid management. Breast cancer in a grandmother at 80 is different from breast cancer in a sister at 35, which may prompt genetic counselling. Bilateral, multiple-primary or male breast cancer, and clusters of breast with ovarian or pancreatic cancer, raise concern for inherited susceptibility.
The genogram
Squares for males, circles for females, a diamond when sex is unknown, a slash through the symbol for deceased with age and cause noted, horizontal lines for partnerships, vertical lines for offspring, and the patient marked with an arrow. Three generations compressed into an image you can read in five seconds. Also ask about family
environment and shared exposures — household smoking, water source, occupational exposure, and who the patient can actually call at two in the morning.