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  2. 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 ...

  3. Operative report - Wikipedia

    en.wikipedia.org/wiki/Operative_report

    The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx), physical examination (PE), consent forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]

  4. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...

  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. History of medicine - Wikipedia

    en.wikipedia.org/wiki/History_of_medicine

    A 12th-century manuscript of the Hippocratic Oath in Greek, one of the most famous aspects of classical medicine that carried into later eras. The history of medicine is both a study of medicine throughout history as well as a multidisciplinary field of study that seeks to explore and understand medical practices, both past and present, throughout human societies.

  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]

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