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Medical history

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The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease state. It includes several subsets detailed below.
Surgical history
Obstetric history
Medications and medical allergies
Family history
Social history
Habits
Immunization history
Growth chart and developmental history
Medical encounters
Chief complaint
History of the present illness
Physical examination
Assessment and plan
The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.
The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.
The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.
The family history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.
The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation.
The history of vaccination is included. Any blood tests proving immunity will also be included in this section.
For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:
This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored.
A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
The physical examination is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).

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