COMPONENTS OF THE MEDICAL HISTORY Flashcards
personal data
you must make sure that you have the correct name, address, telephone number, date of birth, and insurance information. This should be reviewed at every visit. Other parts of the personal database may include the initial physical, lab work, and medication list for the patient. The medication list should also be checked and updated with every visit and in the event that the patient calls into the office with a question or a request for the physician.
chief complaint
this is the patient’s reason for seeking medical care in the patient’s own words. This should contain onset of symptoms, a description of any pain or discomfort, what type of treatment the patient has tried at home, what the patient’s opinion of the problem is, and any other medical treatment that has been sought for this problem.
past medical history
this would include immunization, childhood illnesses, allergies, accidents, surgeries, past hospitalizations, and any major illnesses.
family history
here information about the immediate family members and their state of health or cause of death would be recorded. Information about genetic or familial diseases would be placed in this section.
social history
this section would include information about employment; education; lifestyle choices; diet and exercise; use of alcohol, tobacco, or drugs; and sleep habits. This information can help the care provider to assist the patient in making changes in this area to increase wellness and prevent disease.
systems review
this is the area where the present illness is discussed and charted. It is a head-to-toe systemic assessment that looks at all aspects of the patient. By reviewing all body systems, the provider may discover valuable clues that the patient did not think were relevant to the current situation. This may also uncover early signs of problems that can be addressed before they become problematic for the patient.
