How Do You Write Patient History?

Procedure Steps

1. Introduce yourself, identify your patient and gain consent to speak with them.
2. Step 02 – Presenting Complaint (PC)
3. Step 03 – History of Presenting Complaint (HPC)
4. Step 04 – Past Medical History (PMH)
5. Step 05 – Drug History (DH)
6. Step 06 – Family History (FH)
7. Step 07 – Social History (SH)

What are examples of medical history?

A record of information about a person’s health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.

How do I start my history?

History Taking – Overview

1. Wash your hands.
2. Introduce yourself: give your name and your job (e.g. Dr.
3. Identity: confirm you’re speaking to the correct patient (name and date of birth)
4. Permission: confirm the reason for seeing the patient (“I’m going to ask you some questions about your cough, is that OK?”)

What are the 8 elements of HPI?

CPT guidelines recognize the following eight components of the HPI:

• Location. What is the site of the problem?
• Quality. What is the nature of the pain?
• Severity.
• Duration.
• Timing.
• Context.
• Modifying factors.
• Associated signs and symptoms.

What are the four types of health history?

There are four elements of the patient history: chief complaint, history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH).

How can I get past medical history?

Obtaining an Older Patient’s Medical History

1. General suggestions.
2. Elicit current concerns.
3. Ask questions.
4. Discuss medications with your older patients.
5. Gather information by asking about family history.
6. Ask about functional status.
7. Consider a patient’s life and social history.

How does medical history affect our health?

A family health history can identify people with a higher-than-usual chance of having common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and type 2 diabetes. These complex disorders are influenced by a combination of genetic factors, environmental conditions, and lifestyle choices.

What is history taking of patient?

obtain a patient’s history in a logical, organized, and thorough manner, covering the history of present illness; past medical history (including usual source of and access to health care, childhood and adult illnesses, injuries, surgical procedures, obstetrical history, psychiatric problems, hospitalizations,

What is history based on?

History is the study of change over time, and it covers all aspects of human society. Political, social, economic, scientific, technological, medical, cultural, intellectual, religious and military developments are all part of history.

How do you write the perfect HPI?

The HPI should be written in prose with full sentences and be a narrative that builds an argument for the reason the patient was admitted.

1. Has a starting point (i.e. “the patient was in her usual state of health until 5 days prior to admission.).
2. Has appropriate flow, continuity, sequence, and chronologic order.

How many HPI elements are there?

Two of the eight HPI elements are context and modifying factors. The other elements of the HPI are: Location.

How do I take a good HPI?

It should include some or all of the following elements:

1. Location: What is the location of the pain?
2. Quality: Include a description of the quality of the symptom (i.e. sharp pain)
3. Severity: Degree of pain for example can be described on a scale of 1 – 10.
4. Duration: How long have you had the pain.