How should I format a complete patient case sheet covering demographics, chief complaint, history of present illness, past medical/surgical/obstetric history, medications, allergies, family and social history, review of systems, physical examination, investigations, assessment, and management plan?

How to Write a Complete Patient Case Sheet

A comprehensive patient case sheet should follow a standardized structure with eight core sections: patient demographics, chief complaint with history of present illness, complete past medical/surgical/obstetric history, current medications and allergies, family and social history, systematic review of systems, detailed physical examination findings, and assessment with management plan. 1

Patient Demographics and Identification

Document the following essential identifying information at the top of every case sheet:

• Medical record number - unique hospital identifier 1
• Patient name as it appears on hospital identification 1
• Date of birth (dd/mm/yyyy format) or age in years; for infants under 1 year, document age in months; for neonates under 1 month, document age in days 1
• Gender as indicated in medical records 1
• Race/ethnicity and birthplace 1, 2
• Date and time of admission to hospital 1

Chief Complaint and History of Present Illness

Begin with the patient's primary reason for seeking care in their own words, then systematically document:

• Index date - the exact date when the first symptom or sign appeared 1
• Chronological progression of symptoms with specific dates 1
• Symptom characteristics including onset, location, duration, character, aggravating/relieving factors, radiation, and severity 1
• Associated symptoms relevant to the presenting complaint 1
• Previous similar episodes and their outcomes 1
• Impact on daily functioning including work, school, sleep quality, and social activities 1

For pediatric patients, specifically inquire about behavioral changes, feeding patterns, developmental concerns, and school performance 1

Past Medical History

Document all previous medical conditions with duration, dates of diagnosis, and prior negative tests. 2 This section must include:

Medical Conditions

• Chronic diseases with year of diagnosis and current status 2
• Previous hospitalizations with dates, reasons, and outcomes 2
• History of infectious diseases including HIV status, opportunistic infections, sexually transmitted diseases 2
• Relevant negative findings (conditions specifically ruled out) 2

Surgical History

• All previous surgeries with dates and complications 2
• Recent procedures particularly cardiac surgery or LASIK/PRK (affects IOP measurements) 1
• Blood product transfusions with dates 2

Obstetric History (for women)

• Gynecologic history including menstrual patterns 2
• Pregnancy history including gravida, para, outcomes 2
• Birth control practices and plans for pregnancy 2
• Mammogram history 2

Current Medications and Allergies

Medications

Document comprehensively:

• All prescription medications with specific drug names, doses, frequencies, and duration of therapy 2
• Over-the-counter medications including vitamins and supplements 2
• Complementary/alternative therapies and herbal preparations 1, 2
• Previous medications including those discontinued, with reasons for discontinuation, complications, side effects, and adherence patterns 2, 3
• Corticosteroid use (systemic or topical) 1

Allergies and Adverse Reactions

• Drug allergies with specific dates and detailed description of reaction type 1, 2
• Environmental allergies 1
• Food allergies 2

Failing to document allergies and adverse medication reactions can lead to preventable adverse events. 2

Immunization History

• Childhood vaccinations 2
• Adult boosters including influenza, pneumococcal, COVID-19 2
• Travel immunizations 2

Family History

Document family members with:

• Specific diagnoses particularly glaucoma, cardiovascular disease, diabetes, cancer, psychiatric conditions 1, 2
• Age of onset in affected relatives 2
• Severity and outcomes especially visual loss from glaucoma or death from cardiovascular disease 1
• Three-generation pedigree when genetic conditions suspected 1

Overlooking family history can miss genetic risk factors for disease. 2

Social and Environmental History

Health Behaviors

• Tobacco use - type, amount, duration, pack-years 2
• Alcohol consumption - frequency, quantity, type 2
• Illicit drug use - specific substances, route, frequency 2

Environmental Exposures

• Occupational history with potential workplace exposures 2
• Living situation including household composition 2
• Indoor allergen sources - pets, carpeting, bedding age/type, cleaning methods, heating/cooling systems 1
• Tobacco smoke exposure (active or passive) 1

Functional Status

• Literacy level and primary language 2
• Educational background 2
• Employment status 2
• Travel history including recent and planned travel 2

Review of Systems

Conduct a systematic inquiry covering all organ systems, documenting both positive and pertinent negative findings:

• Constitutional - fever, weight changes, fatigue, malaise 1
• Eyes - vision changes, pain, discharge, photophobia 1
• Ears/Nose/Throat - hearing loss, tinnitus, nasal congestion, epistaxis, sore throat 1
• Cardiovascular - chest pain, palpitations, orthopnea, edema 4
• Respiratory - dyspnea, cough, wheezing, hemoptysis 4
• Gastrointestinal - nausea, vomiting, diarrhea, constipation, abdominal pain 1
• Genitourinary - dysuria, hematuria, frequency 1
• Musculoskeletal - joint pain, swelling, limitation of movement 4
• Neurological - headache, dizziness, weakness, sensory changes 1
• Psychiatric - mood changes, anxiety, sleep disturbances 1
• Skin - rashes, lesions, pruritus 1

Physical Examination

Document findings systematically:

Vital Signs

• Temperature, heart rate, respiratory rate, blood pressure (both arms if indicated), oxygen saturation 1
• Weight and height with calculation of BMI 1

General Appearance

• Overall condition - alert, distressed, comfortable 1
• Nutritional status 1

System-Specific Examination

Document detailed findings for each system, focusing on areas relevant to the chief complaint:

• Head/Eyes/Ears/Nose/Throat - pupillary responses, fundoscopic exam, oropharyngeal examination 1
• Cardiovascular - heart sounds, murmurs, peripheral pulses, edema 1
• Respiratory - breath sounds, respiratory effort, chest wall movement 4
• Abdomen - bowel sounds, tenderness, organomegaly, masses 1
• Musculoskeletal - range of motion, deformities, tenderness 1
• Neurological - mental status, cranial nerves, motor/sensory function, reflexes, gait 1
• Skin - lesions with documentation of type, distribution, extent using body map 1

For skin conditions, estimate percentage of body surface area involved using standardized charts (Lund and Browder). 1

Investigations and Results

List all diagnostic tests performed with dates and results:

• Laboratory studies - complete blood count, metabolic panel, specific disease markers 1
• Imaging studies - radiographs, CT, MRI, ultrasound with interpretation 1
• Specialized testing - ECG, echocardiography, pulmonary function tests, visual fields 1
• Pathology results - biopsies with histopathology and immunofluorescence when indicated 1
• Microbiology - cultures and sensitivities 1

Assessment and Differential Diagnosis

• Primary diagnosis with supporting evidence 5
• Differential diagnoses considered and reasons for inclusion/exclusion 1
• Problem list - numbered list of active medical issues 5
• Severity assessment using validated scoring systems when available 1

Management Plan

Structure the plan by problem, including:

Diagnostic Plans

• Additional testing needed with rationale 5
• Consultations requested with specific questions 1

Therapeutic Plans

• Pharmacological interventions with specific drugs, doses, routes, duration 5
• Non-pharmacological interventions including dietary modifications, activity restrictions 1
• Procedures planned 5

Patient Education

• Disease explanation in patient-appropriate language 3
• Self-monitoring instructions including daily weights, symptom diaries 1
• Warning signs requiring immediate medical attention 1
• Lifestyle modifications - sodium/fluid restriction, alcohol abstinence, smoking cessation 1

Follow-up Plans

• Specific date and time for next evaluation 1
• Parameters to monitor at follow-up 1
• Referrals arranged to specialists or support services 1

Documentation Best Practices

• Use clear, unambiguous language avoiding abbreviations that could be misinterpreted 2
• Document source of information (patient, family, previous records, other providers) 2
• Include pertinent negatives to demonstrate thoroughness of evaluation 2
• Organize information logically using consistent structure across all case sheets 6
• Date and time all entries with legible signature and credentials 6

The primary purpose of medical records is to support patient care; structured documentation improves patient outcomes and physician performance. 6