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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 ...
The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies. Family history The family history lists the health status of immediate family members as well as their causes of death (if known). [19] It may also list diseases common in the family or found only in one sex or the other.
A Fit to Fly Health Certificate (also known as Fit to Fly Letter or Fit for Travel Health Certificate) is a type of doctor's note assessing the risk of an individual that they might pose to either themselves or others during air travel. This type of letter was traditionally most relevant for pregnant passengers—particularly while in the third ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
The decimal outline format has the advantage of showing how every item at every level relates to the whole, as shown in the following sample outline: Thesis statement: --- 1.0 Introduction 1.1 Brief history of Liz Claiborne 1.2 Corporate environment 2.0 Career opportunities 2.1 Operations management 2.1.1 Traffic