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Med Terms Ch. 2

chief complaint the main reason for the patient's visit
history of illness the story of the patient's problem
review of symptoms description of individual body systems in order to discover any symptoms not directly related to the main problem
past medical history other significant past illnesses, like high blood pressure, asthma, or diabetes
past surgical history any of the patient's past surgeries
family history any significant illness that run in the patient's family
social history a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
Location of a clinic note clinic
location of a consult note clinic or hospital
location of an Emergency Department note emergency department
location of an admission summary hospital
location of a discharge summary hospital
location of a progress note inpatient health care facility
clinic note documents a visit
consult note provides an expert opinion on a more challenging problem
discharge summary describes when and why the patient was admitted; documents a longer stay