What level of history would this fall under? I work for a dermatology practice that uses Ederm and this is what most of the history portion of the documentation usually looks like. To me there's only one ROS because I'm thinking the negatives don't count? Would this just be expanded problem focus then?
Chief Complaint and/or History of Present Illness
Complaint(s):
1. Growth on left cheek
Symptom: no pain, itching and or bleeding
Duration: few weeks
Severity: worsening
Modifying Factors: none
Past History
Past Medical History (PMH):
• Denies artificial joints or heart valves, diabetes, glaucoma, hepatitis, hypertension, immunosuppressed, pacemaker,
antibiotics prior to dentistry, skin cancer, hiv/aids, hyperthyroidism, hypothyroidism, lupus, polycystic ovarian
syndrome, blood clot, cancer, kidney disease, asthma and hayfever
Family:
• Admits family history of Acne (sister)
• Denies family history of cancer, malignant melanoma, eczema, lupus, non melanoma skin cancer and
psoriasis
Review of Systems (ROS):
• Admits Integumentary System (skin problems)
• Denies bleeding problems, breathing difficulties, respiratory symptoms, cardiovascular problems or chest
symptoms, nausea,fever,diarrhea, endocrine related symptoms, eye or vision problems, gi symptoms,
joint or musculoskeletal symptoms, neurological symptoms or problems, psychiatric or emotional
difficulties, genital urinary symptoms, ear, nose, mouth or throat symptoms and integumentary
Social:
• Admits: Alcohol Use (social)
• Denies: Illicit drug use, profession, tobacco use
Surgical History
• Denies cancer surgery, gi surgery, plates/rods/screws/stents, heart surgery and joint replacement
Allergy:
• Patient denies allergy to medication
Medications:
• Patient denies taking any medication
Chief Complaint and/or History of Present Illness
Complaint(s):
1. Growth on left cheek
Symptom: no pain, itching and or bleeding
Duration: few weeks
Severity: worsening
Modifying Factors: none
Past History
Past Medical History (PMH):
• Denies artificial joints or heart valves, diabetes, glaucoma, hepatitis, hypertension, immunosuppressed, pacemaker,
antibiotics prior to dentistry, skin cancer, hiv/aids, hyperthyroidism, hypothyroidism, lupus, polycystic ovarian
syndrome, blood clot, cancer, kidney disease, asthma and hayfever
Family:
• Admits family history of Acne (sister)
• Denies family history of cancer, malignant melanoma, eczema, lupus, non melanoma skin cancer and
psoriasis
Review of Systems (ROS):
• Admits Integumentary System (skin problems)
• Denies bleeding problems, breathing difficulties, respiratory symptoms, cardiovascular problems or chest
symptoms, nausea,fever,diarrhea, endocrine related symptoms, eye or vision problems, gi symptoms,
joint or musculoskeletal symptoms, neurological symptoms or problems, psychiatric or emotional
difficulties, genital urinary symptoms, ear, nose, mouth or throat symptoms and integumentary
Social:
• Admits: Alcohol Use (social)
• Denies: Illicit drug use, profession, tobacco use
Surgical History
• Denies cancer surgery, gi surgery, plates/rods/screws/stents, heart surgery and joint replacement
Allergy:
• Patient denies allergy to medication
Medications:
• Patient denies taking any medication
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