Medical History

Medical History

Text: Medical History

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Medical History

The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.

The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and the detailed narrative of what the surgeon did.

The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.

The medical record may contain a summary of the patient’s current and previous medications as well as any medical allergies.

The family history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.

The social history tells of the patient’s relationships, race and religion as well as workplace and type of occupation. It may explain the behaviour of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).

Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation.

The history of vaccination is included. Any blood tests proving immunity will also be included in this section.

For children and teenagers, charts documenting growth is included. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child’s behaviour (such as timing of talking, walking, etc.) is documented within the medical record for much the same reasons as growth.

Within the medical record, individual medical encounters are marked by discrete summations of a patient’s medical history. Hospital admission documentation or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form. Each encounter will generally contain the aspects below:

o Chief complaint. This is the problem that has brought the patient to see the doctor. Information on the nature and duration of the problem will be explored.

o History of the present illness. A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.

o Physical examination. The physical examination is the recording of observations of the patient. This includes the vital signs, muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.

o Assessment and plan. The assessment is a written summation of what are the most likely causes of the patient’s current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).

o Written orders and prescriptions by medical providers are included in the medical record.

o Progress notes. When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These are often entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.

o Test results. The results of testing, such as blood tests (e.g., complete blood count), EKG tracings, digital images of the patient, radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., pulmonary function testing) are included.

Demographics include information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information regarding the patient’s health insurance.

In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.