You should also get in the habit of asking routinely about common conditions that have a genetic component e. The HPI should be a chronological history of the chief concern. A general rule is to use pertinent positives and negatives only when they are relevant to your differential diagnosis.
Heath Care Maintenance: In a general medicine clinic, it's helpful to conclude each note with a Health Care Maintenance section.
He appears to have been a moderately heavy abuser of alcohol for approximately 60 plus years. He travels frequently for long periods of time. In general, organizing by systems rather than problems and diagnoses leads to sloppy thinking because you lose sight of the symptom or problem you are treating and often do not prioritize the problems correctly.
Try to provide a description that would allow your attending to go from room-to-room and identify your patient.
Mary's Hospital. Both of them are completely normal. His differential is benign. When possible, include the dates and location of the hospitalizations. All medications including OTC and supplements should be listed with the dosage.