How To Write A Medical History

Table of contents:

How To Write A Medical History
How To Write A Medical History
Video: How To Write A Medical History
Video: Clinician's Corner: Taking a good patient history 2023, February

The medical history is not limited to listing the patient's complaints and symptoms that have appeared. The doctor must conduct a whole "investigation" in order to obtain maximum information, without which diagnosis and treatment will be impossible.

How to write a medical history
How to write a medical history


Step 1

Write down the patient's personal data - his last name, first name, patronymic, date of birth. Include home address and place of work (or kindergarten / school number, institution name).

Step 2

Find out the patient's complaints. Write down what kind of pain is bothering him and where he thinks the source is. Additional information about seemingly insignificant changes in the patient's well-being, for example, an adjustment in food preferences or a changed perception of odors, will not hurt either. You should not cut off complaints that are not directly related to the source of pain - they can be clues when making a diagnosis.

Step 3

Take a medical history. Since not all people at the doctor's appointment are able to describe their condition in the most detailed and clear way, ask clarifying questions. Ask when exactly and under what conditions the person felt unwell, what preceded it, what he ate or drank, what emotional state he was in, and what kind of environmental impact he experienced. Ask how the pain developed (increased or decreased over time), in what sequence the symptoms occurred. If the patient has taken any medications to relieve the condition, specify their name and dosage.

Step 4

Take the patient's life history. At this stage of work, the doctor is required to be extremely attentive and able to compare disparate facts. Information of any nature can be important, so ask the person who came to the appointment to tell his biography, name the diseases suffered from the moment of birth, describe the conditions of work, life and sex life. Make notes about existing bad habits and possible intoxications, as well as hereditary diseases.

Step 5

Having a detailed medical history on hand, the doctor can make a preliminary diagnosis. To confirm or refute it, an objective study is carried out (general and from narrow specialists) and, if necessary, a referral for additional examination with the help of medical equipment is issued.

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