HELP Interpreting Hospital Physician Note

[Elliphant]

What does this mean (was given to me mistakingly by med assistant. The negative and positives don't make sense to me. Also why are these conditions even listed in the first place? Please help me with this, thank you

 

[Blossom]

What does this mean (was given to me mistakingly by med assistant. The negative and positives don't make sense to me. Also why are these conditions even listed in the first place? Please help me with this, thank you

The plus signs indicate what complaints, symptoms or conditions you either are currently experiencing at the time of the encounter or have in your medical history.
The negative signs indicate things you deny experiencing at the time of examination and/or you have no documented medical history of those symptoms, complaints or conditions.
All of those conditions are listed to prove the physician did a thorough physical assessment. Hopefully if something was marked (+) or (-) the physician actually checked you and looked in your records to come to that conclusion. It's typical for most people visiting the ER to have such a list.
Does that make more sense?

 

[Elliphant]

Thanks for answering. Been trying to get answers on this for awhile now. I understand most of it, but not all. Do you mean deny having whatever the condition listed is, bUT do in fact have it?

 

[Blossom]

By deny I just mean the clinician will ask you directly. For example if you appeared short of breath you would most likely be asked how short of breath you feel not if you are short of breath. You would get a positive for dyspnea or shortness of breath. If you were asked if you had a headache and you said no you would get a negative sign for headache. The clinician counts on you to answer honestly but if they determine you have a condition or symptom you will get a (+). Does that make sense?

 

[Elliphant]

Also why would for instance heart disease even be listed. They know I have it, bUT im experiencing no symptoms at the time ?

 

[Elliphant]

And thank you thank you thank you again. I have asked so many people including medical professionals with no real answers

 

[Elliphant]

Or if I'm experiencing say heart attack sx but they know It's not heart disease theyll put negative?

 

[Blossom]

Heart disease is listed because your main or chief complaint for the ER visit was chest discomfort. It is customary practice I believe to note the presence or absence of heart disease in such scenarios.
ETA: Yes, the negative means basically no known or apparent heart disease.