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The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
CMS required history elements [1] Type of history CC HPI ROS Past, family, and/or social; Problem focused Required Brief N/A N/A Expanded problem focused Required Brief Problem pertinent N/A Detailed Required Extended Extended Pertinent Comprehensive Required Extended Complete Complete
To change this template's initial visibility, the |state= parameter may be used: {{Medical records and physical exam | state = collapsed}} will show the template collapsed, i.e. hidden apart from its title bar. {{Medical records and physical exam | state = expanded}} will show the template expanded, i.e. fully visible.
The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies. Family history The family history lists the health status of immediate family members as well as their causes of death (if known). [19] It may also list diseases common in the family or found only in one sex or the other.
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