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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]
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
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).
A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient.
The patient, Margaret MacDonald, won a court order granting her full access to her own medical record. [31] The case was complicated by the fact that the records were in electronic form and contained information supplied by other providers. McInerney maintained that she didn't have the right to release records she herself did not author.