The Improving Doctor

HPI, PMH or ROS?

This dilemma seems to come up more often than it should when writing up a patient note…My preceptor laid it out today in a very nice way that I felt was worthy of sharing. Hope it helps.

HPI-anything with a possibility of being relevant to patients current condition. Examples include: possible presyncope episode in patient with CHF, H/o diabetes in patient with tingling in feet. Ex. tea-colored urine in patient complaining of fatigue

PMH: Anything with a diagnosis. Ex: 12 year history of DM II controlled by metformin. Ex. Major depression for 5 years treated with fluoxetine

ROS: Any symptom not related (as you deem fit) to the chief complaint. Ex: A patient may be coming in because of cough and dyspnea, she has a history of diabetes and on physical exam you find out she has felt tingling and loss of sensation in her feet recently. The cough and dyspnea are in the HPI. The diabetes should be captured in the PMH, and the loss of sensation should be documented in the ROS.

To recap: HPI: Related to chief complaint. PMH: Any diagnosis. ROS: Any symptoms unrelated to CC.