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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 ...
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).
The physician will take a history of present illness, or HPI, of the CC. [1] This describes the patient's current condition in narrative form, from the time of initial sign/symptom to the present. [10] It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded. [1]
Some notes include a "reason for consultation", which is similar but may address a physical finding from a physician as opposed to a symptom from a patient. history of present illness (HPI) "Pt is a 30 yo female (with a PMH of x and y) presenting with a 3 hour history of abdominal pain..." Including a separate paragraph summarizing related history.
In medicine, a social history (abbreviated "SocHx") [1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.
Chief complaints (CC) - what made patients seek medical attention. History of present illness (HPI) - circumstances relating to chief complaints. Past medical history (PMHx) Past surgical history; Current medications; Allergies; Family history (FHx) Social history (SocHx) Physical examination (PE) Laboratory results (Lab)
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".
The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.