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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.
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The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.
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".
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Theoretically, free software such as GNU Health and other open source health software could be used or modified for various purposes that use electronic medical records i.a. via securely sharing anonymized patient treatments, medical history and individual outcomes (including by common primary care physicians). [48]