Chapter 2: History Taking and the Medical Record

Introduction

Proper care of a patient, for more than a single episode of care, requires a medical record documenting the observations and data needed for their care. Ideally, this record will be available to all providers at any site at any time, a goal that electronic medical records makes feasible. The record should contain all patient data in a standard format: demographics; active and past medical problems; surgical and injury history; medications, allergies, and drug intolerances; family, social, and sexual history; personal habits; prostheses; and preventive care services. Using standardized forms for data collection enables information to be recorded uniformly for each patient, which facilitates rapid review of pertinent information at each visit. It is important to enter information so that it is always current; for example, record the first names of children and siblings with their year of birth (rather than age).

Outline of the Medical Record

The medical history is recorded in a standard sequence, differing minimally from one institution to another. The following sequence is suggested for adults. A different order giving prominence to the birth history is often preferred by pediatricians.

1. Identification

2. Informant

3. Chief complaints (CCs)

4. History of present illness (HPI)

5. Past medical and surgical history (PMH)

   1. General health

   2. Chronic illnesses and conditions

   3. Operations and injuries

   4. Hospitalizations

6. Family history (FH)

7. Social history (SH)

8. Review of systems (ROSs)

9. Medications

10. Allergies and medication intolerances

11. Preventive services, including immunizations

12. Physical examination (PE)

13. Laboratory and imaging studies

14. Assessment/Problem list

15. Plan

Procedure for Taking a History

Description of the Medical History

The medical history is a history of this person. The current episode of illness cannot be fully understood without knowing the unique history of the person, not just as patient, but as a person in society. The details of their FH and SH provide context for their medical care. All serious illnesses including surgeries, injuries, and hospitalizations are recorded. The status of preventative care is also established. Verification of these events by review of the previous medical records is advised.

A medical history is more than a list of facts. It is a unique literary form in which the physician writes an account of perceptions and events as related by the patient. The history may be given spontaneously, or may require some probing, returning to areas of uncertainty for clarification. The history should record key statements in the patient’s words. A history is usually incomplete at the first telling; repeat questioning after an interval of hours or days will yield additional information. Take particular care to establish the sequence of events. Neither the patient in ...