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Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information.
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details. Much of the history is obtained by asking questions.
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 information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
[1] [2] Contextual information may include personal history, social history, and other medical history. [2] a physical examination of a patient: [1] [2] This varies based on the purpose of the interview. explaining results and planning: [1] [2] This aims to ensure a shared understanding, and allowing for shared decision-making. [1]
This is a list of mnemonics used in medicine and medical science, categorized and alphabetized. A mnemonic is any technique that assists the human memory with information retention or retrieval by making abstract or impersonal information more accessible and meaningful, and therefore easier to remember; many of them are acronyms or initialisms which reduce a lengthy set of terms to a single ...
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".