Surgery Documentation

Surgical Documentation
S. E. Wilson, MD
Surgical History and Physical Examination
Identifying Data: Patient's name, age, race, sex; referring physician.
Chief Compliant: Reason given by patient for seeking surgical care and the duration of the symptom. History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent, cramping, stabbing, radiating); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or relieving factors. Vomiting (color, character, blood, coffee-ground emesis, frequency, associated pain). Change in bowel habits; rectal bleeding, character of blood (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing. Past Medical History (PMH): Previous operations and indications; dates and types of procedures; serious injuries, hospitalizations; diabetes, hypertension, peptic ulcer disease, asthma, heart disease; hernia, gallstones. Medications: Aspirin, anticoagulants, hypertensive and cardiac medications, diuretics. Allergies: Penicillin, codeine, iodine. Family History: Medical problems in relatives. Family history of colon cancer, cardiovascular disease. Social History: Alcohol, smoking, drug usage, occupation, daily activity.
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