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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]
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 ...
History & physical; Specialist reports, such as those for medical imaging or pathology; An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [3]
History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. [ 11 ] Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure.
Original file (6,741 × 5,477 pixels, file size: 5.65 MB, MIME type: application/pdf) This is a file from the Wikimedia Commons . Information from its description page there is shown below.
Because it relates to all of medicine, the single most proper placement would be in Category:Medical mnemonics, which is a direct sub-category of Category:Medicine. --Scott Alter 22:29, 4 April 2008 (UTC) I remain unconvinced why multiple applicable categories aren't kept. Sure, SAMPLE can be used outside EMS, but it is a core tool of BLS.