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The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews.
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]
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases.
A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. [17]
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
Our patients are being harmed until we can get our act together,” said Dr. Davida Schiff, whose hospital network, Mass General Brigham in New England, instituted a new policy this year that ...
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
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