A medical history is an important part of every encounter between medical personnel and a patient.The level of detail depends on the patient's complaint and whether time is a factor.A complete history can include a review of the patient's symptoms and a past medical history.
Step 1: The patient's name, age, height, weight and chief complaint should be taken down.
Step 2: The primary history needs to be gathered.
The patient can ask for more information on the complaints.Ask about anything the patient was unclear about or that you don't understand.To get specific numbers for things like how long the patient has had the symptoms or how much pain, use a scale from 0 to 10.The patient tells you what to record.Add your interpretation to what you hear.
Step 3: The secondary history can be expanded.
You want to know if the symptoms the patient is experiencing are related to the chief complaint.The key to a correct diagnosis is the associated symptoms.The patient may not realize that the symptoms are related to the complaint.This section of the medical history requires you to interpret what you hear.
Step 4: Take the secondary history.
Something in the patient's past medical history may have something to do with the complaint.You can home in on specific problems or events that support the diagnosis if you're fairly certain about it.
Step 5: There should be a review of symptoms.
This is a list of what the patient feels is not normal.It's a good idea to have a list of body areas in mind as you question the patient.Ask the patient about the constitution of their skin and breasts, eyes, ears, nose, throat and mouth.
Step 6: The patient needs to be interviewed for a past medical history.
This is information about the patient's health, not just the current complaint.Allergies and drug reactions Current medications, including over-the-counter drugs Current and past medical or psychiatric illnesses or conditions Past hospitalizations immunization status Use of tobaccoAsk about the patient's current sexual activity and history.If it includes exposure to hazardous materials.