Guidelines for Creating a Patient's Chart


Personal data

Name, surname, birthdate, domicile, date of admission, brief reason for hospitalization.

Patient's history

Pt's medical history should be brief. Family history should contain the most important repeated and chronic diseases in the family, both somatic and mental. It is necessary to put down chronological data in diseases influencing the present medical state (diabetes mellitus diagnosed when, treated since…). Conversely the precise chronological data can be missing in illnesses not related to the presenting illness and don't influence patient's present state (i.e. in the majority of cases of appendectomy). Some groups of diseases need targeted questions concerning previous medical history like head trauma or recurrent otitis media in suspected bacterial meningitis, alcohol abuse in liver injuries, biliary colics or proven cholelithiasis in case of jaundice, vaccination in rash illnesses etc. You must not forget to ask about allergies and long-term medication.

You should not forget a dietary mistake (in diarrheal illnesses), parenteral exposure and contact with infected people (in hepatitis), tick-bite and outdoor activities (in nervous system infections), drinking water from non-reliable sources (in nervous system infections, intestinal infections, hepatitis), contact with an infected person (in exanthematic illnesses, parotitis, meningococcal invasive illnesses, hepatitis), contact with animals (in adenopathies) etc. The pt´s travel history is important in a number of illnesses or symptoms (unexplained fevers, diarrheal illnesses, hepatitis etc.) and information about vaccinations (especially rash illnesses, mumps, hepatitis, tick-born encephalitis etc.).

Dates should be mentioned in the present medical history (not names of days in a week or relative time facts), reason for hospitalization should be written explicitly (i.e. "admitted for worsening of diarrhea"). No argot or colloquial expressions should be used ("burping" etc.). Pt's own expressions can be mentioned in brackets but only to a limited extend. Little corrections and completion of pt's history are acceptable (for example pt doesn't remember the name of the medicine, however does have a box of it with him). It is appropriate to end the history of the present illness with a statement: "The patient is hospitalized in the ID clinic since..., the suspicion of presented diagnosis was confirmed/excluded, during treatment the pt's health state improved/worsened, main complaints are now..."

Physical examination

Physical examination on admission contains mainly findings related to the diagnosis and can be expressed negatively (no Holzel's sign, no meningeal signs). Physical examination includes general inspection and description of individual parts of the body from head down to feet. Pulse, blood pressure, and temperature must not be forgotten. The same applies to the weight in infants. If they are missing, it's necessary to put why. The state of consciousness, meningeal signs and brief neurological status in nervous system infections, signs of dehydration, circulation parameters and abdomen findings in enteric infections, rash, mucosal findings, lymphadenopathy, organomegaly in exanthematic infections etc. can not be excluded in a shortened version of the physical examination. The size of the record of the physical examination is not strictly determined but record too short raises suspicions about not examining the patient carefully. Pathological findings are often needed to be precised (i.e. information about lymphadenomegaly needs to be completed with information about size, consistency, tenderness, fixation etc.) Examination might be limited by the cooperation of the patient and his or her ability (this can be referred to in the record). It's clear that the patient doesn't sit up and stand up after the lumbar puncture, we won't let an exhausted patient squat etc. Fabricated data are evaluated very negatively. Hematomes, scars, badly healed fractures etc. are to be described as side findings (mainly for forensic reasons).

Presumptive diagnosis

Put main disease threatening the patient's health and the reason for hospitalization in the infectious disease dept. on top (they are usually the same). Put chronic complaints next and put side diagnoses in the end. Diagnosis should logically arise from patient's history, physical findings and suggested or given laboratory tests. Work diagnosis represents to a certain extent a hypothesis, don't be afraid to put down a concrete diagnosis. When data are missing put down general diagnosis (syndrome) or a suspected illness. Do not put single symptoms which occur in a given disease as a part of the diagnosis (i.e. infectious mononucleosis with hepatic lesion, varicella with fever, acute encephalitis with diffuse EEG abnormality). On the other hand - commentary to the findings which do not usually occur in the context of a given diagnosis must be discussed (like crackles in lungs in case of gastroenteritis). Unconfirmed diagnoses can be mentioned with a remark "in the patient's medical history" (i.e. hypercholesterolemia in pt's medical history = hypercholesterolaemia in anamnesi). Avoid expressions like "acute virosis" etc. Concerning the formal part: it's convenient to write all in Latin or all in English. In your differential diagnosis put down alternative diagnoses which really come into consideration and not all theoretical possibilities (like yellow fever in a patient with jaundice etc.).

Laboratory and additional tests

The concept of laboratory and additional tests contains:

(1) Basic tests which serve for rough orientation about the kind of disease (bacterial or viral) and affection of a respective organ or system (CSF examination, chest X-ray).

(2) Other tests informing about the general state and severity of the disease (serum electrolytes, blood gases etc.). Certain examinations represent necessary screening of all hospitalized patients (erythrocyte sedimentation rate, chemical urinanalysis).

(3) Specific examinations focused usually on revealing the etiology of the disease (stool culture, serological tests). Special tests should be mentioned only with a remark that they might be carried out in case of positive or negative results of other tests (for example liver sonography in the presence of signs of cholestatic liver lesion, brain CT when focal neurological finding or an unusual course of meningitis are present etc.).


Recommendation should contain information:

(1) About the type of the diet - in numbers or words (like: strict fat reduction, diabetic etc.).

(2) About the regime - strict bed rest, relative rest, without restrictions.

(3) About the medication - drug name with dosing (for each particular patient, that means not 50mg/kg/day, but for example 500mg TID PO). Do not forget the symptom-based and supportive treatment (antipyretics, analgesics, gargles etc.).

Date and student's name

Put down the date and your name.

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© Dec-27-2023