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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]
An online version called Five Wishes Online was introduced in April 2011 allowing users to complete the document using an online interface or print out a blank version to complete by hand. An updated version, renamed Five Wishes Digital, debuted in 2022, including options for all 50 states, and fully digital signing and witnessing options. [7]
History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on ...
In a medical encounter, a past medical history (abbreviated PMH) [1] is the total sum of a patient's health status prior to the presenting problem. Questions to include [ edit ]
The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.
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