… [T]here is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.
Proper care of a patient for more than a single episode of care requires a medical record documenting the data specific to the patient and their care. Ideally, this record should be available to all providers at any site of care at any time, an ideal within grasp with electronic medical records. The record should contain, preferably in standardized formats, basic patient data, such as their demographics, list of active and past medical problems, surgical history, injury history, medication history, allergies, and drug intolerances, sexual history, family history (FH), social history (SH), personal habits, prostheses used, preventive care services, and specific counseling provided. Using standardized forms for data acquisition and filing enables the information to be recorded in a uniform way for each patient, allowing rapid review of the pertinent information at each visit. It is important to enter information in such a way that it is always current; for example, in the FH list the first names of children and siblings with their year of birth (rather than age).
The parts of the medical history follow a standardized sequence, differing only in small details from one institution to another. The following sequence is suggested for adult patients. A different order giving prominence to the birth history is often preferred by pediatricians.
Chief complaints (CC)
History of present illness (HPI)
Past medical and surgical history
Chronic and episodic illnesses
Operations and injuries
Family History (FH)
Social History (SH)
Review of systems (ROS)
Allergies and medication intolerances
Preventive care services
Physical examination (PE)
Laboratory and imaging studies
Definition of the Medical History
The medical history is an account of the events in the patient's life that have relevance to the patient's mental and physical health. The elements of the medical history are: (1) sensations that can never be observed by the examiner, (2) abnormalities noted by the patient at some past time so they cannot be confirmed by the PE, (3) events in the past, not readily verifiable, such as former diagnoses or treatments, and (4) the patient's FH and description of their social situation.
Much more than the patient's unprompted narrative, it is a specialized literary form in which the physician writes an account of the perceptions and events as related by the patient or other informants. The history may be offered spontaneously or secured by skillful probing. Often, the history is best elaborated by repeat questioning after a time, as the patient is encouraged to reflect on their experience. In taking the history, the clinician should record key statements in the patient's words. The history is the patient's ...