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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
Infobox for medical conditions Template parameters [Edit template data] This template prefers block formatting of parameters. Parameter Description Type Status name name Name of disease or medical condition (should be the same as the title of the article) Example Posttraumatic stress disorder String required synonym synonym synonyms Common terms for the illness or condition. Example Upper ...
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]
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 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 ...
[[Category:Medicine infobox templates]] to the <includeonly> section at the bottom of that page. Otherwise, add <noinclude>[[Category:Medicine infobox templates]]</noinclude> to the end of the template code, making sure it starts on the same line as the code's last character.
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