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  2. SAMPLE history - Wikipedia

    en.wikipedia.org/wiki/SAMPLE_History

    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]

  3. Template:Medical records and physical exam - Wikipedia

    en.wikipedia.org/wiki/Template:Medical_records...

    To change this template's initial visibility, the |state= parameter may be used: {{Medical records and physical exam | state = collapsed}} will show the template collapsed, i.e. hidden apart from its title bar. {{Medical records and physical exam | state = expanded}} will show the template expanded, i.e. fully visible.

  4. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information.

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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.

  6. History of the present illness - Wikipedia

    en.wikipedia.org/wiki/History_of_the_present_illness

    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).

  7. Review of systems - Wikipedia

    en.wikipedia.org/wiki/Review_of_systems

    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).

  8. OPQRST - Wikipedia

    en.wikipedia.org/wiki/OPQRST

    Each letter stands for an important line of questioning for the patient assessment. [ 3 ] [ 4 ] This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note , for later reference.

  9. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.

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