With the CC and HPI behind us, let’s tackle “the lists” today: the Medications, Past Medical History (PMH), Social History (SHx), Family History (FHx), and Review of Systems (ROS). Some considerations:
Imports: EMRs can automatically import lists into your note, which is both a convenience and a hazard. Automatic imports can save you key strokes, but they can also litter your notes with inaccurate, incomplete, and outdated information. If your patient’s “COPD” turned out to be sarcoidosis, you need to update the diagnosis. If your patient no longer takes aspirin, you need to get rid of it. If your patient’s smoking history was left out, you need to put it in. It’s your job to identify what’s true, what’s false, and what’s missing- and make the changes.
Placement: It’s up to you to decide what goes in the HPI and what goes in the lists. In general, information related to the acute problem goes in the HPI. For example, if you admit a patient with acute asthma, you should describe their multiple intubations and chronic steroid treatment in the HPI. In contrast, if the same patient presents with DKA, you should place their asthma in the PMH.
Details: Without going overboard, share details. What caused the CKD? How extensive is the RA? How much does the patient drink?
What You Write and What You Say: These lists can get long, so you will generally say less than you write. You don’t need to discuss your 99-year-old’s family history on rounds, even if you included it in your note.* Just say, “The Family History is non-contributory.” Limit what you say out loud to issues needing attention. If your audience has questions, they can ask.
For the individual sections:
Meds: Confirm what the patient is truly taking. Inaccurate med lists are a major source of medical error, so attend to the details, including doses. Include OTC meds and supplements.
PMH: Don’t ask me why it’s called the “past” medical history. Are there present and future histories too? I guess “past” is meant to distinguish prior illnesses from the “present” one described in the HPI. The PMH is a common source of chart lore, and I’ve personally cured many patients of chronic diseases they never actually had by hitting the delete button.** The PMH often contains duplicate information, like “CHF” and “HFrEF.” In general, keep the more descriptive diagnoses (HFrEF) and delete the generic ones (CHF).
Social History: The SHx is your chance to describe your patient as a full person.*** One day in the MICU, we discovered two famous musicians on our service, because we asked about their jobs. One day on Fitkin, we met a lineman from the Green Bay Packers. Another day, we met a construction worker who helped build Smilow. There’s so much to learn: Where was your patient born? Where have they lived? Where have they traveled? What are their hobbies? Did they serve in the military and, if so, did they see action? You can learn about exposures- at home, at work, at play, from pets, from sexual partners, etc. Historically, we’ve placed tobacco, alcohol, and recreational drug use in the SHx, but it really belongs in the PMH.
Family History: The FHx is especially important when you’re considering inheritable diseases, like early onset CAD and familial cancers. You should always ask about biological parents and siblings. If you’re hunting for rare genetic diseases, extend the pedigree with grandparents, aunt and uncles, cousins, and biological children.
Review of Systems: It bears repeating that the ROS is distinct from pertinent positives and negatives, which go in the HPI. Consider the ROS your chance to uncover problems distinct from the main concern- for example, discovering that your patient with cellulitis has lost weight, or that your patient with Lyme Disease found a lump in her breast. You can use the ROS to ask about vaccinations and age-appropriate cancer screening, like mammograms and Pap smears. Your comprehensive review can save a life.
Last Words: Long, chaotic, inaccurate lists are useless: they overwhelm your audience and bury crucial information. Your mission is to create lists that are streamlined, accurate, and thoughtfully detailed. Your patients and teammates are counting on you.
Have a wonderful Sunday, everyone. We’re expecting thunderstorms today in Bath, so we’ll be heading to the Maine Maritime Museum before driving back to Connecticut tomorrow.
*If both her parents lived to 105, tell us, because that’s cool.
**It’s one of my super-powers