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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 ...
A PMH is considered one of three elements of the "Past, Family, and Social History" (abbreviated as PFSH): [6] 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 ...
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 information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. [11] Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure.
Early mentions of family medical histories in medical literature date from the 1840s. Henry Ancell mentioned inquiring about the family history of a patient in a medical case study in 1842, noting that the patient's presenting concern appears to be present in relatives and remarking on the prolific reproduction of her female relatives. [4]
Chronological table of epidemic and pandemic events in human history Event Years Location Disease Death toll (estimate) Ref. 1350 BC plague of Megiddo c. 1350 BC Megiddo, land of Canaan: Amarna letters EA 244, Biridiya, mayor of Megiddo complains to Amenhotep III of his area being "consumed by death, plague and dust" Unknown [29]
The Clinical History of the [Spanish] National Health System (Historia Clínica Digital del Sistema Nacional de Salud, HCDSNS) is intended to guarantee citizens and health professionals access to whatever clinical information is relevant for medical care of a particular patient. This history should be available at all authorized locations, but ...