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… [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.
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Safe high-quality medical care requires a medical record documenting the observations and data needed for the patients’ care. Ideally, this record will be accessible to all providers at any site at any time, a goal that electronic medical records make feasible. A standard format is used to record: demographics; active and past medical problems; surgical history; medications, allergies, and drug intolerances; family, social, and sexual history; personal habits; and preventive care services. A standard format facilitates rapid review and updating 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).
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OUTLINE OF THE MEDICAL RECORD
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The medical history is recorded in a standard sequence. The following sequence is suggested for adults.
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Identification
Informant
Chief complaints (CCs)
History of present illness (HPI)
Past medical and surgical history (PMH)
General health
Chronic illnesses and conditions
Operations and injuries
Hospitalizations
Family history (FH)
Social history (SH)
Review of systems (ROSs)
Medications
Allergies and medication intolerances
Preventive services, including immunizations
Physical examination (PE)
Laboratory and imaging studies
Assessment/Problem list
Plan
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The medical history is the history of this person. The current 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 family and social history 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.
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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 the telling nor the physician in the recording should introduce medical terms or jargon; be sure that the story is told in everyday language. The history is the patient’s story of their illness, not the physician’s interpretation of the patient’s history. The challenge is to understand the patient’s experience and interpretation of their illness.