By Mille Vissing, MD, Mie Pilegaard Bjarnesen, BCs. med. and Mia Wangsmo Steffenssen, MD
Medication: List of prescription, over the counter, and alternative medication including cod liver oil and ginger extracts. Note pauses in medication and their duration.
Social Status: Occupation, relevant hobbies, living situation, marital status, children, and need for home assistance.
Drug, Tobacco and Alcohol use: Tobacco should be listed in current use and history in pack years. A pack year is the equivalent of 1 year of smoking 20 cigarettes per day i.e. 1 packyear = (number of cigarettes per Day x number of years smoking)/20. Alcohol and any other recreational drug use should be noted especially for patients where treatment of withdrawal symptoms can be necessary.
Special investigations: Results from blood samples, ECGs, and diagnostic imaging (e.g. CT, PET/CT, chest-x-rays). Indicate dates of the examinations.
Tentative diagnosis: Note the tentative diagnosis. Can also include the diagnosis code.