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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 first Spanish medical colleges were formally established in 1894. Compulsory registration for all doctors was debated between 1898 and 1900 but wasn’t established till 1917. From 1893 there was a growing need amongst the medical profession to create a professional association and with this in mind, the local colleges were founded.
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 ...
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 ...
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The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. [1] A medical record includes a variety of types of "notes" entered over time by healthcare ...
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
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).