Questions – yields 89% (full credit per rubric)
1 How can I help you today?
2 Are there any other symptoms or concerns we should discuss?
3 When did your abdominal pain start?
4 Does anything make the pain in your abdomen better or worse?
5 Where more precisely is your abdominal pain?
6 How severe (1-10) is your abdominal pain?
7 Do you have nausea and/or vomiting?
8 Do you have any allergies?
9 Are you taking any prescription medications?
10 Are you taking any over the counter or herbal medications?
11 What does the pain in your abdomen feel like?
12 Does the pain in your abdomen radiate someplace else?
13 Is the pain in your abdomen affected by what, when, or how much you eat?
14 Any change in the frequency of your bowel movements?
15 Any previous medical, surgical, or dental procedures?
16 Are you unable to pass gas?
17 Can you tell me about any current or past medical problems you’ve had?
18 Do you have a history of bowel obstruction?
19 Have you or any family member had a history of inflammatory bowel disease?
20 Have you had the pain in your abdomen before?
21 Do you have heart disease and/or have you ever had a heart attack?
22
Have you lost weight?
23 Have you been vomiting anything that looks like blood or coffee grounds?
24 Do you have any black tar or foul-smelling stools?
25 Have you ever been hospitalized?
26 Do you have diarrhea?
27 Do you have a history of volvulus?
28 Do you avoid eating because you are worried about the pain?
29 How long does the pain in your abdomen last?
30 Is there any blood in your stools or with your bowel movements?
31 How often does this abdominal pain occur?
32 Have you been diagnosed with chronic mesenteric ischemia?
33 Do you now, or have you ever had cancer?
FYI – The electronic health record is not listed on the rubric as being graded, check with your professor before spending the time completing the EHR. Some professors still wanted to see that it was completed, some did not require it – the EHR information is here for you just in case.
Electronic Health Record – History
Reason for Encounter Abdominal Pain
HPI Patient presents with a progressive 3-day history of severe cramping abdominal pain 5/10 with associated nausea, vomiting on undigested food
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