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What Is A Medical History Summary?


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.

What are examples of medical history?

Past medical history

  • Childhood illnesses.
  • Major adult illnesses.
  • Past surgical history, including type, date, and location of past surgical procedures.
  • Medications. Prescription drugs.
  • Allergies. Drugs or environmental factors.
  • Prior injuries (e.g., motor vehicle accidents, falls)
  • Prior hospitalizations and/or.
  • Immunizations.

How do you structure a medical history?

The basic structure of the history is as follows:

  1. Presenting complaint (PC)
  2. History of presenting complaint (HPC)
  3. Past medical history (PMHx)
  4. Drug history (DHx)
  5. Family history (FHx)
  6. Social history (SHx)
  7. Systems review (SR)
  8. Ideas, concerns, expectations (ICE)

Why is a medical history important?

Medical history is important because when GPs have more information about a patient’s medical history, health professionals can deliver the most appropriate and effective treatment or support for their concerns.

How do I get a detailed medical 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 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 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.


How do you ask someone about past medical history?

Generally speaking, most patient history conversations are as follows:

  1. Greet the patient by name and introduce yourself.
  2. Ask, “What brings you in today?” and get information about the presenting complaint.
  3. Collect past medical and surgical history, including any allergies and any medications they’re currently taking.

What is history of presenting complaints?

Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (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).

How do you focus on history?

In documenting a focused history and performing a focused physical examination, you need to explore the chief complaint, the history of the present illness, the past medical history, medications and allergies, the family history and social history, the occupational history, and the sexual history that are relevant to

What is included in a health summary?

Shared health summary Represents a patient’s health status at a point in time. This will include known information in four key areas: patient’s medical conditions, medicines, allergies/adverse reactions and immunisations. A patient has only one current shared health summary at a time.

What is the most common medical condition?

The 25 most common medical diagnoses

  • Hypertension.
  • Hyperlipidemia.
  • Diabetes.
  • Back pain.
  • Anxiety.
  • Obesity.
  • Allergic rhinitis.
  • Reflux esophagitis.

What is patient summary?

The ‘Patient Summary’ is a concise document that can inform clinicians at the point of care. It is applicable to planned care but is particularly important in cases when an unscheduled or unplanned health event occurs and the patient’s clinical history is unknown to the attending clinician(s).

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