The medical history represents the single most important opportunity to obtain individualized medical information. Since it is an opportunity and not a guaranteed source of information, the caregiver or patient during the interview may unknowingly miss critical data. Language proficiency, patient and caregiver cognitive abilities, readiness to change behavior, interest in seeking health care, and personal comfort with the practitioner are only a few factors that may influence the ability to obtain vital information. The information in this chapter can enhance the clinician’s ability to obtain patient information and to delve more deeply into patient motivation and understanding than the classically structured patient history. It assumes that it is a caregiver of a patient that is being interviewed, but the principles described apply to interviewing patients when developmentally appropriate.
Table 4-1 describes the traditional patient history. The typical history focuses on gathering a variety of specific information in a brief period of time. The very important information recorded in the traditional history is an organized synopsis and a necessary summary of medications, surgeries, and major medical events. The degree of detail present in the various components is highly variable and should be tailored in response to the purpose and duration of the visit. The traditional history provides early valuable insight into factors influencing a patient’s motivation for seeking care.
TABLE 4-1COMPONENTS OF THE CLASSIC PATIENT HISTORY |Favorite Table|Download (.pdf) TABLE 4-1COMPONENTS OF THE CLASSIC PATIENT HISTORY
| ||Content |
|Chief complaint (CC) ||The patient- or primary caregiver–stated reason for being present at the visit |
|History of the present illness (HPI) ||A detailed synopsis of factors most pertinent to the chief complaint; focuses on timing, duration, severity, and symptoms associated with the chief complaint |
|Past medical history (PMH) ||A listing of medications, allergies, surgeries, hospitalizations, chronic illnesses, and other significant medical occurrences |
|Review of systems (ROS) ||An organ system–based evaluation of complaints and previous diagnoses not otherwise covered in the past medical history |
|Family history (FH) ||A summary of illnesses present in the patient’s family history, recorded in relation to the patient |
|Social history (SH) ||A synopsis of psychosocial and other factors affecting care; at a minimum, social history should include living situation, school/work history, and support system |
The challenge of the medical history is to not lose sight of the patient and caregiver’s often unstated goals. A significant hazard of the traditional medical history is losing valuable information that may not present itself if the patient feels the clinician is not listening to them. A clinician may unwittingly prevent a patient or caregiver from expressing concerns and from identifying barriers to care. Often, large parts of the medical history can be obtained from patients and caregivers in the form of surveys or questionnaires completed either independently or with the assistance of trained staff. Additionally, the first two components ...