Nursing Assignment!

NURS 6512: Comprehensive Health History Reference Sheet

⚠ Reminder: The health history includes **subjective data only** — information

provided by the patient about their symptoms, perceptions, and experiences.

Objective findings belong in the physical exam section.

Chief Complaint (CC)

• State the patient’s main reason for visit — concise and focused.

• Use the patient’s own words in quotes (1–2 words or one short sentence).

• Example: “Sore throat for two days.” or “Shortness of breath.”

History of Present Illness (HPI) – OLDCARTS + Pertinent History

• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written

in complete sentences.

• Avoid bullet points. Tell the story of the symptom(s) using the data you collected.

• O – Onset: When did it start?

• L – Location: Where is it? Does it radiate?

• D – Duration: Constant or intermittent?

• C – Character: Describe the quality (sharp, dull, throbbing).

• A – Aggravating factors: What makes it worse?

• R – Relieving factors: What makes it better?

• T – Timing: Pattern, frequency, time of day.

• S – Severity: 0–10 pain scale or functional impact.

• Include associated symptoms and pertinent negatives (important symptoms the

patient denies).

• Incorporate pertinent history such as recent illness, exposures, travel, medications

tried, previous episodes, or related chronic conditions.

• Example: The HPI should read as a full paragraph that flows logically and reflects

critical thinking — not as a list of OLDCARTS items.

Past Medical History (PMH)

• Chronic illnesses (HTN, DM, asthma, etc.)

• Childhood illnesses (if relevant)

• Hospitalizations and psychiatric history

Surgical History (PSH)

• List all surgeries/procedures with year, indication, and complications

Medications

• List all: prescription, OTC, herbal, and supplements

• Include name, dose, route, frequency, indication

• Note adherence and side effects Allergies

• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.)

• Document tolerated alternatives if known

Preventive Health

• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal

• Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA

• Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision

Social History

• Tobacco: Type, amount, duration, quit attempts

• Alcohol: Type, frequency, quantity (CAGE if indicated)

• Substance use: Illicit or prescription misuse

• Occupation: Exposures, stress, satisfaction

• Living situation & support system

• Safety: IPV, firearms, seatbelt use

• Social Determinants of Health (SDOH): Housing, food, transport, access, finances

Review of Systems (ROS)

These are subjective symptoms that the patient reports. No objective exam findings

should be included here.

• General: Fever, chills, weight change, fatigue

• Skin: Rashes, lesions, itching

• HEENT: Vision, hearing, congestion, sore throat

• Cardiac: Chest pain, palpitations, edema

• Respiratory: Cough, SOB, wheezing

• GI: N/V/D, constipation, pain, appetite

• GU: Dysuria, frequency, hematuria

• MSK: Joint pain, stiffness, weakness

• Neuro: Headache, dizziness, numbness, seizures

• Psych: Mood, anxiety, sleep

• Endo: Heat/cold intolerance, polyuria/polydipsia

• Heme: Easy bruising/bleeding

NURS 6512: Comprehensive Health History Reference Sheet

⚠ Reminder: The health history includes **subjective data only** — information

provided by the patient about their symptoms, perceptions, and experiences.

Objective findings belong in the physical exam section.

Chief Complaint (CC)

• State the patient’s main reason for visit — concise and focused.

• Use the patient’s own words in quotes (1–2 words or one short sentence).

• Example: “Sore throat for two days.” or “Shortness of breath.”

History of Present Illness (HPI) – OLDCARTS + Pertinent History

• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written

in complete sentences.

• Avoid bullet points. Tell the story of the symptom(s) using the data you collected.

• O – Onset: When did it start?

• L – Location: Where is it? Does it radiate?

• D – Duration: Constant or intermittent?

• C – Character: Describe the quality (sharp, dull, throbbing).

• A – Aggravating factors: What makes it worse?

• R – Relieving factors: What makes it better?

• T – Timing: Pattern, frequency, time of day.

• S – Severity: 0–10 pain scale or functional impact.

• Include associated symptoms and pertinent negatives (important symptoms the

patient denies).

• Incorporate pertinent history such as recent illness, exposures, travel, medications

tried, previous episodes, or related chronic conditions.

• Example: The HPI should read as a full paragraph that flows logically and reflects

critical thinking — not as a list of OLDCARTS items.

Past Medical History (PMH)

• Chronic illnesses (HTN, DM, asthma, etc.)

• Childhood illnesses (if relevant)

• Hospitalizations and psychiatric history

Surgical History (PSH)

• List all surgeries/procedures with year, indication, and complications

Medications

• List all: prescription, OTC, herbal, and supplements

• Include name, dose, route, frequency, indication

• Note adherence and side effects Allergies

• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.)

• Document tolerated alternatives if known

Preventive Health

• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal

• Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA

• Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision

Social History

• Tobacco: Type, amount, duration, quit attempts

• Alcohol: Type, frequency, quantity (CAGE if indicated)

• Substance use: Illicit or prescription misuse

• Occupation: Exposures, stress, satisfaction

• Living situation & support system

• Safety: IPV, firearms, seatbelt use

• Social Determinants of Health (SDOH): Housing, food, transport, access, finances

Review of Systems (ROS)

These are subjective symptoms that the patient reports. No objective exam findings

should be included here.

• General: Fever, chills, weight change, fatigue

• Skin: Rashes, lesions, itching

• HEENT: Vision, hearing, congestion, sore throat

• Cardiac: Chest pain, palpitations, edema

• Respiratory: Cough, SOB, wheezing

• GI: N/V/D, constipation, pain, appetite

• GU: Dysuria, frequency, hematuria

• MSK: Joint pain, stiffness, weakness

• Neuro: Headache, dizziness, numbness, seizures

• Psych: Mood, anxiety, sleep

• Endo: Heat/cold intolerance, polyuria/polydipsia

• Heme: Easy bruising/bleeding