© 20

21

Walden University

Page

1

of

2

Name:

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA:

Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness

(HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (

Include history of parents,

maternal/p

aternal

Grandparents, siblings,

and children):

Review of Systems:

From head

–

to

–

toe, include each system that covers the Chief Complaint,

History of Present Illness, and History).

Remember that the information you include in this

section is based on what t

he patient tells you. To ensure that you include all essentials in your

case, refer to Chapter 2 of the Sullivan text.

General:

Include any recent weight changes, weakness, fatigue, or fever, but

do not

restate HPI data here

.

HEENT:

Neck:

© 2021 Walden University Page 1 of 2

Name:

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,

and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,

History of Present Illness, and History). Remember that the information you include in this

section is based on what the patient tells you. To ensure that you include all essentials in your

case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not

restate HPI data here.

HEENT:

Neck: