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  2. Social history (medicine) - Wikipedia

    en.wikipedia.org/wiki/Social_history_(medicine)

    In medicine, a social history (abbreviated "SocHx") [1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

  3. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    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 ...

  4. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase such as "no family h/o of heart or lung problems" may be used to specifically indicate that questions about a system were asked. social history (SH) "Denies x3"

  5. Past medical history - Wikipedia

    en.wikipedia.org/wiki/Past_Medical_History

    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 patient at risk"; Social history: "an age-appropriate review of past and current activities".

  6. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies. Family history The family history lists the health status of immediate family members as well as their causes of death (if known). [19] It may also list diseases common in the family or found only in one sex or the other.

  7. 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]

  8. Psychiatric history - Wikipedia

    en.wikipedia.org/wiki/Psychiatric_history

    9 Social history. 10 ... A psychiatric history is the result of a medical process where ... This article mainly covers the initial assessment history taking of a ...

  9. Mental status examination - Wikipedia

    en.wikipedia.org/wiki/Mental_status_examination

    The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...

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