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Old 04-03-2014
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Default Question about patient note

I'm just starting prep so I'm a little confused. In the patient note where we mention history and physical exam findings supporting our diagnosis should we only mention pertinent positives?
For example if it's a an appendicitis case in a reproductive age group female, apart from Hx of right lower quad pain, fever, nausea and vomiting, can we also add no Hx of amenorrhea? Basically can we mention negative history or findings to support our diagnosis? Or should we only support with pertinent positives?

Hope my question is clear. Thanks!
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Old 04-03-2014
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Default Yes you absolutely can!!

You can write pertinent negatives in the physical findings if you have time and if you don't have much else to written in the physical findings which is most often the case.
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Old 04-04-2014
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I went to a CS class, and I was told NOT to put negative findings as support evidence. You can put pertinent negatives in the HPI and physical exam. But a negative finding won't necessarily support a diagnosis, it is used to rule out other diagnosis.
Using amenorrhea as an example: a pt with RLQ pain but with no fever, no nausea/vomiting, and no amenorrhea means pt has appendicitis since you are saying "no amenorrhea" supports appendicitis.
Same thing applies to putting "normal physical exam" on the physical finding...
I left most of my physical finding area blank.
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