An American National Standard

Designation: E 2184 – 02

Standard Specification for

Healthcare Document Formats1
This standard is issued under the fixed designation E 2184; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (e) indicates an editorial change since the last revision or reapproval.

1. Scope Health Record (EHR)2

1.1 This specification addresses requirements for the head- E 1762 Guide for Electronic Authentication of Health Care
ings, arrangement, and appearance of sections and subsections Information2
when used within an individual’s healthcare documents. This E 1869 Guide for Confidentiality, Privacy, Access, and Data
specification will facilitate identification and retrieval of health Security Principles for Health Information including
information in a manner that will enhance the quality and Computer-Based Patient Records2
efficiency of health services. Use of this specification in E 1902 Guide for Management of the Confidentiality and
conjunction with XML DTDs (extensible markup language Security of Dictation, Transcription, and Transcribed
document type definitions) and the EHR (electronic health Health Records2
records) would further enhance efficiency in time and cost. E 1985 Guide for User Identification and Authorization2
This specification applies across multiple healthcare settings in E 1986 Guide for Information Access Privileges to Health
which healthcare documents are generated, such as hospitals, Information2
clinics, skilled nursing facilities, ambulatory care facilities, E 1987 Guide for Individual Rights Regarding Health In-
outpatient surgery centers, and private healthcare providers’ formation2
offices. E 1988 Guide for Training of Persons Who Have Access to
1.2 This specification addresses the headings, arrangement, Health Information2
and appearance of sections and subsections of healthcare E 2084 Specification for Authentication of Healthcare In-
documents, however generated (dictation/transcription, speech formation Using Digital Signatures2
recognition, touch-screen entry, and so forth) and whether E 2085 Guide on Security Framework for Healthcare Infor-
displayed electronically or on paper. It does not address the mation2
titles of healthcare documents or the content of sections and E 2086 Guide for Internet and Intranet Healthcare Security2
subsections. E 2147 Specification for Audit and Disclosure Logs for use
1.2.1 The author of a healthcare document may choose to in Health Information Systems2
summarize subsection information within a general section E 2182 Specification for Clinical XML DTDs in Health-
rather than creating subsections. care2
1.3 The format and content of patient-identifying data are E 2183 Guide for XML DTD Design, Architecture, and
addressed in Guide E 1384. Implementation2
1.4 Issues of confidentiality and security are addressed in 3. Terminology
Guide E 1869, Guide E 1902, Guide E 1762, Guide E 1985,
Guide E 1986, Guide E 1987, Guide E 1988, Specification 3.1 Definitions:
E 2084, Guide E 2085, and Guide E 2086, as well as in 3.1.1 alias, n—heading synonymous with and which shall
Specification E 2147. be replaced by the specified heading. No alias (synonym) shall
1.5 Issues of XML DTDs are addressed in Specification be used in place of the specified heading. The aliases presented
E 2182 and Guide E 2183. are examples only, that is, no attempt has been made to identify
all potential aliases.
2. Referenced Documents 3.1.2 amendment, n—a correction or addendum to a docu-
2.1 ASTM Standards: ment.
E 1384 Guide for Content and Structure of the Electronic 3.1.3 author, n—the person originating content for a health-
care document.
3.1.4 document, n—see healthcare document.
3.1.5 format, n—the arrangement of the content of a health-
1
This specification is under the jurisdiction of ASTM Committee E31 on care document for display. In this specification, format refers to
Healthcare Informatics and is the direct responsibility of Subcommittee E31.28 on
Electronic Healthcare Records.
Current edition approved Jan. 10, 2002. Published March 2002.
2
Annual Book of ASTM Standards, Vol 14.01.

Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.

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 E 2184 – 02
the sequencing of the sections and subsections used in a benefits include improved access to health information for
healthcare document, the appearance of their headings, their reimbursement, legal, research, and statistical purposes.
line spacing, and their alignment. 4.3 Consistent with provider policy, the application of this
3.1.6 healthcare document, n—healthcare information, specification is the responsibility of the author of the healthcare
however generated, pertinent to a specific individual and document, the medical transcriptionist or other person respon-
recorded to serve a specific use. sible for entering information into the healthcare document, or
3.1.7 healthcare information, n—worded, numeric, imaged, a combination thereof.
or data-streamed material used to communicate the healthcare 4.4 Annex A1 specifies the headings of sections and sub-
experience of, and related services for, an individual. sections (when used), their arrangements, and their appearance
3.1.8 health record, n—healthcare information retrievable in history and physical examination reports, consultation re-
from one or more sources, however displayed, pertinent to an ports, emergency department notes, clinic notes, nurses notes,
individual, used to describe and measure that individual’s therapists notes, treatment summaries (including discharge,
health status and health care over time and across settings, to transfer, and death summaries). These headings for sections
facilitate healthcare management through one or more episodes and subsections may also appear in other healthcare docu-
of care, including preventive or health maintenance activities. ments.
3.1.9 medical transcriptionist, n—a medical language spe-
cialist who interprets and transcribes dictation by physicians 5. Specifications
and other healthcare professionals regarding patient assess- 5.1 Sections and Subsections: Headings, Arrangement, and
ment, workup, therapeutic procedures, clinical course, diagno- Appearance—The specified headings shall be utilized for
sis, prognosis, and so forth, in order to document patient care sections and subsections when used within individual health-
and facilitate delivery of healthcare services. AAMT (1)3 care documents, shall be ordered and arranged as listed, and
3.1.10 practitioner, n—an individual who is qualified to shall be presented with the appearance specified. Definitions
practice a health care profession, for example, physician, nurse, are offered to clarify the meanings of the headings. Sample
or physical therapist. Practitioners are often required to be aliases are noted to identify some terms that shall be converted
licensed as defined by law. to assure a uniform specified heading; other aliases shall be
3.1.11 provider, n—a business entity that furnishes health similarly converted. Comments are included as appropriate.
care to a consumer; it includes a professionally licensed 5.1.1 Arrangement:
practitioner who is authorized to operate a healthcare delivery 5.1.1.1 Section Headings—When used, section headings
facility. E 1384 shall be placed in the sequence specified and shall be left-
3.2 Acronyms: margin aligned. Each section and its heading shall be separated
3.2.1 AAMT—American Association for Medical Transcrip- from the previous section by a line space or the equivalent. The
tion initial entry regarding a section (even if that initial entry is a
3.2.2 CPT-4—Physician’s Current Procedural subsection heading) shall begin on the line immediately
Terminology—Fourth Edition (2) following the section heading and shall be left-margin aligned.
3.2.3 DTD—document-type definition 5.1.1.2 Subsection Headings—When used, subsection head-
3.2.4 ICD-9-CM—International Classification of Diseases, ings shall be placed in the sequence specified and shall be
Ninth Edition, Clinical Modification (3) left-margin aligned under their respective sections. When a
3.2.5 JCAHO—Joint Commission on Accreditation of subsection heading is the initial entry following a section
Healthcare Organizations heading, that subsection heading shall be entered on the line
3.2.6 SOAP—Subjective, Objective, Assessment, Plan immediately following the section heading. Each subsection
3.2.7 XML—extensible markup language and its heading shall be separated from the previous section or
subsection by a line space or the equivalent.
4. Significance and Use 5.1.1.3 Inclusion—None of the sections or subsections is
4.1 This specification is intended to result in consistency in required, but if such information is included, the specified
the names of headings of sections and subsections (when used), headings shall be used.
their arrangement, and their appearance in individuals’ health- 5.1.1.4 Content Following Section or Subsection
care documents. Headings—Content following headings shall begin on the next
4.2 Primary benefits of this consistency in presentation line and shall be aligned at the left margin throughout, below
include: (1) facilitating identification and retrieval of health the heading. No content shall follow on the same line as a
information in a manner that will enhance the quality and section or subsection heading. Multiple paragraphs within
efficiency of health services, patient safety, and patient privacy, sections and subsections shall be separated by a line space.
(2) providing easier access to relevant health information 5.1.2 Appearance:
within a record, (3) enabling greater information sharing within 5.1.2.1 Section heading terms shall be in uppercase letters
and among enterprises, and (4) promoting greater efficiency in (for example, PAST HISTORY).
transcription and other forms of data capture. Secondary 5.1.2.2 Subsection heading terms shall be in initial capital
letters followed by lowercase letters with the exception of
conjunctions, articles, and prepositions of fewer than four
3
The boldface numbers in parentheses refer to the list of references at the end of letters, which shall be in all lowercase letters (for example,
this standard. Alcohol and Substance Abuse).

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 E 2184 – 02
5.1.2.3 Content following headings shall be in uppercase 6. Keywords
and lowercase according to standard language usage, with the
6.1 appearance; arrangement; format; headings; healthcare
exception that the term ALLERGIES and any SUBSTANCE to
document; sections; subsections
which the individual is allergic shall be in all uppercase letters.

ANNEX

(Mandatory Information)

A1. HEADINGS FOR SECTIONS AND SUBSECTIONS OF HISTORY AND PHYSICAL EXAMINATION REPORTS AND
RELATED HEALTHCARE DOCUMENTS

A1.1 Headings for sections and subsections—The headings A1.5.2 HISTORY OF PRESENT ILLNESS replaces HPI,
below shall be applied to sections and subsections when used Present Illness, PI, History of Present Health, and other aliases.
within history and physical examination reports, consultation
reports, emergency department notes, clinic notes, nurses A1.6 Section Heading PAST HISTORY
notes, therapists notes, treatment summaries (including dis- A1.6.1 Definition—The individual’s significant health his-
charge, transfer, and death summaries). The headings may also tory other than that pertinent to the current reason for seeking
apply to other healthcare documents. healthcare services. If any information on the individual’s past
A1.1.1 In certain instances specific formats for portions of history is included in the document, it shall be included in this
healthcare documents are in accepted usage, for example, section. This section may include information on medical,
SOAP notes and problem oriented medical reports. When the surgical, psychiatric, social, family, dental/oral, perinatal,
section or subsection terms in the following list are utilized medication, immunization, alcohol and substance abuse, diet,
within such format conventions, this standard specification education, work history, and so forth, in narrative form or as
shall be applicable to such use. subsections.
A1.6.2 PAST HISTORY replaces Past Medical History,
A1.2 Patient-identifying Data—Patient-identifying data are PMH, Health History, and other aliases.
addressed in Guide E 1384. A1.6.3 Subsection Headings:
A1.3 Section Heading: CHIEF COMPLAINT(S) A1.6.3.1 Medications. Enter non-current medications here.
Address current medications in A1.8.
A1.3.1 Definition—The patient’s stated reason(s) for pre-
A1.6.3.2 Immunizations
senting, (typically presented as one complaint in the patient’s
A1.6.3.3 Education
own words).
A1.6.3.4 Habits
A1.3.2 CHIEF COMPLAINT replaces Presenting Com-
A1.6.3.5 Social
plaint, Primary Complaint, Complaint, CC, Presenting Prob-
A1.6.3.6 Family
lem, and other aliases.
A1.6.3.7 Medical
A1.3.3 Comments—If there are multiple complaints of
A1.6.3.8 Surgical
equal significance to the patient, identify them collectively as
A1.6.3.9 Psychiatric (Psychiatric replaces Mental and other
CHIEF COMPLAINTS. When multiple complaints are priori-
aliases.)
tized by the patient, present the primary one as the CHIEF
A1.6.3.10 Obstetrical/Gynecologic
COMPLAINT and include others in a subsection with the
A1.6.3.11 Dental/Oral
heading Additional Complaints.
A1.6.3.12 Alcohol and Substance Abuse (This topic may be
A1.3.3.1 Additional Complaints.
addressed in the subsection Habits rather than within its own
A1.4 Section Heading: REASON FOR ENCOUNTER subsection.)
A1.4.1 Definition—Condition, diagnosis, or treatment plan A1.6.3.13 Diet
for which the individual is entered into a service, whether A1.6.3.14 Work History
inpatient or outpatient. More formal statement than CHIEF
COMPLAINT and presented in practitioner’s terms rather than A1.7 Section Heading: ALLERGIES
patient’s. A1.7.1 Definition—Hypersensitivity to specified medica-
A1.4.2 REASON FOR ENCOUNTER replaces Reason for tions and other substances. All of the individual’s known
Admission, Reason for Visit, Reason for Service, and other allergies shall be listed here, even though they may be listed in
aliases. other sections. Manifestations and treatment of the allergies
should also be addressed here.
A1.5 Section Heading: HISTORY OF PRESENT A1.7.2 ALLERGIES replaces Sensitivities and other
ILLNESS aliases.
A1.5.1 Definition—History related to the Chief Complaint A1.7.3 Comments: Substances to which a person is allergic
or Reason for Encounter, or both. shall be entered in capital letters.

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 E 2184 – 02
A1.7.4 Multiple ALLERGIES. precede the physical examination instead of follow it. This
A1.7.4.1 Enter multiple ALLERGIES in a numbered, verti- section may include information on body systems and organs
cal list. in narrative form or as subsections.
A1.10.2 PHYSICAL EXAMINATION replaces PE, Exam,
A1.8 Section Heading: CURRENT MEDICATIONS Examination, Physical, Physical Exam, Pertinent Physical
A1.8.1 Definition—All medications that the patient was Findings, and other aliases.
taking upon presentation shall be listed here, even though they A1.10.3 Subsection Headings:
may be listed in other sections. Address non-current medica- A1.10.3.1 General
tions in A1.6.3.1. A1.10.3.2 Vital Signs
A1.8.2 CURRENT MEDICATIONS replaces Medications, A1.10.3.3 Skin (Skin replaces Integument, Dermatologic,
Meds, Current Drugs, and other aliases. Derm, and other aliases.)
A1.10.3.4 HEENT (HEENT replaces the collective heading
A1.9 Section Heading: REVIEW OF SYSTEMS “Head, Eyes, Ears, Nose, Throat,” and other aliases. When
these body parts are addressed separately rather than collec-
A1.9.1 Definition—Systematic record of the status and
tively, use the headings as indicated in A1.10.3.5-A1.10.3.8.)
functioning of the body’s systems and regions. This section
A1.10.3.5 Head
may include information on various body systems in narrative
A1.10.3.6 Eyes
form or as subsections.
A1.10.3.7 Ears
A1.9.2 REVIEW OF SYSTEMS replaces ROS, System
A1.10.3.8 Nose
Review, and other aliases.
A1.10.3.9 Mouth and Throat (Mouth and Throat replaces
A1.9.3 Subsection Headings:
ENT and other aliases.)
A1.9.3.1 General
A1.10.3.10 Neck
A1.9.3.2 Skin (Skin replaces Integument, Dermatologic,
A1.10.3.11 Lymph Nodes (Lymph Nodes replaces Lym-
Derm, and other aliases.)
phatics and other aliases.)
A1.9.3.3 Head (Head replaces HEENT and other aliases.)
A1.10.3.12 Thorax and Lungs (Thorax and Lungs replaces
A1.9.3.4 Eyes (Eyes replaces Ocular and other aliases.)
Chest and other aliases.)
A1.9.3.5 Ears (Ears replaces Otorhinolaryngology and other
A1.10.3.13 Cardiovascular (Cardiovascular replaces Heart,
aliases.)
Cor, and other aliases.)
A1.9.3.6 Nose, Sinuses (Nose, Sinuses replaces Otorhino-
A1.10.3.14 Breasts
laryngology, ENT, and other aliases.)
A1.10.3.15 Abdomen
A1.9.3.7 Mouth and Throat (Mouth and Throat replaces
A1.10.3.16 Pelvic (Pelvic replaces Genitorectal and other
ENT and other aliases.)
aliases)
A1.9.3.8 Neck
A1.10.3.17 Ano-rectal (Ano-rectal replaces Rectal, Geni-
A1.9.3.9 Breasts
torectal, Prostate, and other aliases.)
A1.9.3.10 Respiratory (Respiratory replaces Cardiorespira-
A1.10.3.18 Peripheral Vascular
tory, Pulmonary, Lungs, Chest, and other aliases.)
A1.10.3.19 Musculoskeletal
A1.9.3.11 Cardiac (Cardiac replaces Cardiorespiratory, Car-
A1.10.3.20 Extremities
diovascular, Cor, Heart, and other aliases.)
A1.10.3.21 Neurologic
A1.9.3.12 Gastrointestinal (Gastrointestinal replaces GI and
A1.10.3.22 Mental Status
other aliases.)
A1.9.3.13 Genitourinary (Genitourinary replaces Urinary, A1.11 Section Heading: MENTAL STATUS
GU, and other aliases.) EXAMINATION (4)
A1.9.3.14 Gynecologic (Gynecologic replaces OB/GYN, A1.11.1 Comment: The mental status examination may or
Reproductive, and other aliases.) may not be included in the physical examination, and it may
A1.9.3.15 Musculoskeletal (Musculoskeletal replaces Mus- either precede or follow the physical examination.
cular, Skeletal, and other aliases.) A1.11.2 MENTAL STATUS EXAMINATION replaces
A1.9.3.16 Peripheral Vascular (Peripheral Vascular replaces Mental Status, Mental Status Exam, MSE, and other aliases.
Vascular and other aliases.) A1.11.3 Subsection Headings:
A1.9.3.17 Neurologic A1.11.3.1 General Description
A1.9.3.18 Hematologic A1.11.3.2 Emotion (Emotion replaces Affect, Mood, and
A1.9.3.19 Endocrine other aliases.)
A1.9.3.20 Psychiatric (Psychiatric replaces Mental and A1.11.3.3 Perceptual Disturbances
other aliases.) A1.11.3.4 Thought Process
A1.11.3.5 Orientation
A1.10 Section Heading: PHYSICAL EXAMINATION A1.11.3.6 Memory
A1.10.1 Definition—Includes examiner’s findings on visual A1.11.3.7 Impulse Control
inspection, palpation, auscultation, and percussion of the pa- A1.11.3.8 Judgment
tient. The physical examination may or may not include mental A1.11.3.9 Insight
status examination, and the mental status examination may A1.11.3.10 Reliability

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A1.12 Section Heading: DIAGNOSTIC STUDIES A1.17.3.2 Therapeutic
A1.12.1 Definition—Studies made to determine the nature A1.17.3.3 Diagnostic
of a disease or condition. Differentiation between DIAGNOS- A1.17.3.4 Discharge
TIC STUDIES (A1.12) and PROCEDURES (A1.19) shall be A1.17.3.5 Standing
resolved through guidance provided in CPT or ICD9 coding A1.17.3.6 Teaching
conventions. A1.17.3.7 Problem Prevention
A1.12.2 DIAGNOSTIC STUDIES replace Tests, Diagnos- A1.17.3.8 Activities of Daily Living
tic Tests, Laboratory Findings, Lab Studies, Lab Tests, Lab A1.17.3.9 Monitoring
Results, Ancillary Tests, X-rays, Imaging Studies, Pathology,
and other aliases. A1.18 Section Heading: COURSE
A1.12.3 Subsection Headings: A1.18.1 Definition—Narrative discussion of events and sig-
A1.12.3.1 Laboratory nificant findings, treatment, and response over the encounter
A1.12.3.2 Pathology period.
A1.12.3.3 Imaging (Imaging replaces X-rays and other A1.18.2 COURSE replaces Hospital Course, Treatment
aliases.) Course, and other aliases.
A1.12.3.4 Cardiovascular
A1.12.3.5 Other A1.19 Section Heading: PROCEDURES/
INTERVENTIONS
A1.13 Section Heading: FINDINGS A1.19.1 Comment: Differentiation between DIAGNOSTIC
A1.13.1 Definition—Clinically significant observations. STUDIES (A1.12) and PROCEDURES/INTERVENTIONS
Such observations may be included under the heading Diag- (A1.19) shall be resolved through guidance provided in coding
nostic Studies or one of its subsections, or may be stated here. conventions such as CPT, ICD, ABCcodes, SNOMED, NIC,
A1.13.2 FINDINGS replaces Pertinent Findings and other and so forth.
aliases. A1.19.2 PROCEDURES/INTERVENTIONS replaces Pro-
cedures Performed, Operations, and other aliases.
A1.14 Section Heading: DIAGNOSIS or DIAGNOSES
A1.14.1 Definition—The decision reached regarding the A1.20 Section Heading: PRACTITIONER
nature of a disease or condition. A1.20.1 Definition—An individual who is qualified to prac-
A1.14.2 DIAGNOSIS or DIAGNOSES replaces Assess- tice a health care profession, for example, physician, nurse,
ment, Impression, and other aliases. physical therapist. Practitioners are often required to be li-
A1.14.3 Subsection Headings: censed as defined by law.
A1.14.3.1 Admitting (Admitting replaces Admission and A1.20.2 PRACTITIONER replaces Provider, Physician,
other aliases.) and other aliases.
A1.14.3.2 Primary (Primary replaces Principal and other A1.20.2.1 Credentials (MD, RN, DO, etc.) shall accompany
aliases.) the practitioner’s name.
A1.14.3.3 Secondary A1.20.2.2 Function (surgeon, consultant, etc.) when identi-
A1.14.3.4 Provisional (Provisional replaces Presumptive fied shall accompany the practitioner’s name.
and other aliases.) A1.20.3 Subsection Headings:
A1.20.3.1 Primary
A1.15 Section Heading: PROGNOSIS A1.20.3.2 Assistant
A1.15.1 Definition—A forecast of the probable course
and/or outcome of a disease or condition. A1.21 Section Heading: ADVANCE DIRECTIVES
A1.15.2 PROGNOSIS replaces Outlook, Predicted Course, A1.21.1 Definition—Instructional directive in written form
and other aliases. (appropriately witnessed) that indicates the patient’s wishes for
medical treatment should he or she become incapacitated and
A1.16 Section Heading: PLAN unable to participate in medical decision making. (3)
A1.16.1 Definition—Proposed program of action. The A1.21.2 ADVANCE DIRECTIVES replaces Directive to
PLAN may include the Orders if they are integral to the Plan. Physicians, Medical Directive; Terminal Care Document; Ad-
A1.16.2 PLAN replaces Admission Plan, Treatment Plan, vance Medical Directive, Directives, Living Will, Organ Do-
Discharge Plan, and other aliases. nation, Do Not Resuscitate, and other aliases.

A1.17 Section Heading: ORDERS A1.22 Accountability—The document’s author or other per-
A1.17.1 Definition—A directive, for example, about treat- son responsible for entering into the record the author’s
ment, examination, drugs, and other care given to a patient.(5) statements shall be identified, as well as the date and place of
A1.17.2 ORDERS replaces Treatment Orders, Medication origination and of entry.
Orders, Further Care, and other aliases. A1.22.1 The author of the document shall be identified by
A1.17.3 Subsection Headings: name or code according to institutional policy or contract
A1.17.3.1 Admission terms.

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 E 2184 – 02
A1.22.2 The person (for example, medical transcriptionist) A1.22.3.2 Time—The time shall include the hour, minute,
responsible for entering the author’s statements for the docu- and time zone, based on a 24-hour clock.
ment shall be identified by name or code according to A1.22.3.3 Place—The place shall be identified by city, state
institutional policy or contract terms. or province (where applicable), and country.
A1.22.3 The date, time, and place of origination and of
production shall be stated. A1.23 Distribution—The parties to whom the document is
A1.22.3.1 Date of origination shall include the month, day, to be distributed shall be noted.
and year that the author dictated or otherwise created the
report.
A1.24 Amendments—Amendments to the original docu-
A1.22.3.1.1 Date of production shall include the month,
ment shall be identified by the heading AMENDMENT in all
day, and year that the person responsible for entering the
author’s statements did so. capital letters. Amendments may be corrections or addenda to
A1.22.3.1.2 If the author does direct entry, without the the original document. Each shall meet the specifications for
assistance of another person, the date of origination and date of accountability as specified in A1.22.
entry shall be the same.

APPENDIXES

(Nonmandatory Information)

X1. HEADINGS EXAMPLE

X1.1 The following example illustrates the arrangement

and appearance of headings and the special treatment of
allergies.

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT
Nausea and vomiting.

ADDITIONAL COMPLAINT
Right knee pain.

REASON FOR ENCOUNTER

Dehydration.

HISTORY OF PRESENT ILLNESS

The patient experienced onset of nausea around noon 3 days ago,
followed shortly thereafter by vomiting. Vomiting has been frequent
since then,….

PAST HISTORY
Social History
The patient is married and has two teenage children.

Medical History
The patient has a history of….

ALLERGIES
The patient is allergic to SULFA DRUGS.

CURRENT MEDICATIONS
The patient takes…

REVIEW OF SYSTEMS
Gastrointestinal
The patient is 8 weeks post-cholecystectomy.

Genitourinary
Hysterectomy 1985, including tubal ligation.

PHYSICAL EXAMINATION
General
The patient is a well-nourished, well-developed….

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 E 2184 – 02
Vital Signs
Blood pressure 140/80. Pulse 92 and regular. Respirations 17.

HEENT
Head normocephalic. Eyes…. Ears… Nose and throat….

Respiratory
Lungs clear to percussion and auscultation.

Cardiac
Normal rate and rhythm.

Gastrointestinal
Right upper quadrant tender to touch. No rebound….

Pelvic
Normal external female genitalia.

FINDINGS
The patient is severely dehydrated…

DIAGNOSIS
Pending further evaluation.

PLAN
Admit. Control dehydration.

ORDERS
Medications ordered include…

Ima Doctor, MD
Admitting Physician

ADVANCE DIRECTIVES
None on file. Not discussed.

Author: 17864
Date and time of origination: 5/4/2000 10:15 PT
Place of origination: Los Angeles, CA, USA

Transcriptionist: wr214
Date and time of production: 5/8/2000 14:20 CT
Place of production: Chicago, IL, USA

X2. TEMPLATE FOR SECTIONS AND SUBSECTIONS

X2.1 The following serves as a template for the sections NOTE X2.1—Not all sections and subsections from Annex A1 are
and subsections described in Annex A1. included because not all headings apply in a single report.

CHIEF COMPLAINT

REASONS FOR ENCOUNTER

HISTORY OF PRESENT ILLNESS

PAST HISTORY
Medications

Immunizations

Education

Habits

Social

Family

Medical

Surgical

Psychiatric

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 E 2184 – 02

Obstetrical/Gynecologic

Dental/Oral

Alcohol and Substance Abuse

Diet

Work History

ALLERGIES

CURRENT MEDICATIONS

REVIEW OF SYSTEMS
General

Skin

Head

Eyes

Ears

Nose, Sinuses

Mouth and Throat

Neck

Breasts

Respiratory

Cardiac

Gastrointestinal

Genitourinary

Gynecologic

Musculoskeletal

Peripheral Vascular

Neurologic

Hematologic

Endocrine

Psychiatric

PHYSICAL EXAMINATION
General

Vital Signs

Skin

HEENT

Neck

Lymph Nodes

Thorax and Lungs

Cardiovascular

Breasts

Abdomen

Pelvic

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 E 2184 – 02

Ano-rectal

Peripheral Vascular

Musculoskeletal

Extremities

Neurologic

MENTAL STATUS
EXAMINATION (4)
General Description

Emotion

Perceptual Disturbances

Thought Process

Orientation

Memory

Impulse Control

Judgment

Insight

Reliability

DIAGNOSTIC STUDIES
Laboratory

Pathology

Imaging

Cardiovascular

Other

FINDINGS

DIAGNOSIS
Admitting

Primary

Secondary

PROGNOSIS

PLAN

ORDERS
Admission

COURSE

PROCEDURES/INTERVENTIONS

PRACTITIONER
Primary

Assistant

ADVANCE DIRECTIVES
Author
Date and time of origination
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AMENDMENTS

REFERENCES

(1) The AAMT Book of Style for Medical Transcription, Claudia Tessier, (4) Textbook of Psychiatry, 3rd edition, Eds: Hales, RE, Yodofsky, SC,
AAMT, 1995 Talbott, JA, American Psychiatric Press Inc., Washington, DC, Lon-
(2) CPT-4: Physician’s Current Procedural Terminology—Fourth Edition don, England, 1999.
(3) ICD-9-CM: International Classification of Diseases, Ninth Edition, (5) Lexikon: Dictionary of Health Care Terms, Organizations, and Acro-
Clinical Modification nyms, 2nd edition, O’Leary et al., JCAHO, 2001.

BIBLIOGRAPHY

(1) E 1633 Specification for Coded Values Used in the Computer- (7) Ambulatory Care Documentation, American Health Information
Based Patient Record. Management Association (AHIMA), 1997.
(2) E 1959 Guide for Requests for Proposals Regarding Medical (8) American Heritage Dictionary, Houghton Mifflin Company, 4th
Transcription Services for Healthcare Institutions. edition, 2000.
(3) 2001 Hospital Accreditation Standards, Joint Commission on (9) Data Elements for Emergency Department Systems, National Cen-
Accreditation of Healthcare Organizations (JCAHO), 2001. ter for Injury Prevention and Control, Centers for Disease Control
(CDC), 1997.
(4) A Guide to Physical Examination and History Taking, 5th edition. (10) Documentation Requirements for the Acute Care Patient Record,
J.B. Lippincott Company, 1991. Glondys, AHIMA, 1999.
(5) Accreditation Manual for Hospitals, JCAHO, 2001. (11) Dorland’s Illustrated Medical Dictionary, 29th edition, W.B. Saun-
(6) Accreditation 99: Surveyor Guidelines for the Accreditation of ders Company, 2000.
Managed Care Organizations, National Committee on Quality (12) Stedman’s Medical Dictionary, 27th edition, Lippincott Williams &
Assurance (NCQA), 1998. Wilkins, 2000.

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