Medical History Taking Format

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What is Medical History Taking Format?

Medical History Taking Format is a structured approach used by healthcare professionals to gather relevant information about a patient's medical history. This includes details about past illnesses, surgeries, medications, allergies, and family history.

What are the types of Medical History Taking Format?

There are several types of Medical History Taking Formats that healthcare providers may use, including:

Chronological format - Organizes medical history information in chronological order.
Problem-oriented format - Focuses on specific health issues or concerns.
Organ system format - Divides medical history information based on different organ systems.

How to complete Medical History Taking Format

Completing a Medical History Taking Format is essential for providing comprehensive and personalized care to patients. Here are some steps to help you complete the form:

01
Start by introducing yourself and explaining the purpose of the medical history taking process.
02
Ask open-ended questions to encourage the patient to provide detailed information.
03
Record the information accurately and legibly on the designated form.
04
Review the completed form with the patient to ensure accuracy and ask for any additional details if necessary.
05
Ensure that the medical history form is stored securely and confidentiality is maintained.

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Questions & answers

Key Components Chief complaint (CC) History of present illness (HPI) Review of systems (ROS) Past, family and/or social history (PFSH)
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.
Here are some important areas an effective medical history form should cover: Patient contact information. Age and gender. History of surgeries and treatments. Previous tests and scans. Dates and timeline of symptoms. Family medical history. Past diseases and illnesses. Known allergies.
In general, a medical history includes an inquiry into the patient's medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
How To Properly Document Patient Medical History In A Chart Presenting complaint and history of presenting complaint, including tests, treatment and referrals. Past medical history – diseases and illnesses treated in the past. Past surgical history – operations undergone including complications and/or trauma.
“What problems have brought you here today?” “Tell me what problems you've been having.” “Tell me what you've come to see me about.” “What's brought you to the hospital today?” “What's been troubling you?” “How can I help you?” “What can I do for you?” “I see that you have backache. Please tell me more about it.”
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