When treating a patient, information gathered by any means can crucially guide and direct care. Many initial encounters with patients will include asking the patient's medical history, while subsequent visits may only require a review of the medical history and possibly an update with any changes. Obtaining a medical history can reveal the relevant chronic illnesses and other prior disease states for which the patient may not be under treatment but may have had lasting effects on the patient's health. The medical history may also direct differential diagnoses.
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.
A complete medical history includes a more in-depth inquiry into the patient's medical issues which includes all diseases and illnesses currently being treated, and those which have had any residual effects on the patient's health. A surgical history to include all invasive procedures the patient has undergone. Family history is another aspect of the patient's medical history with potential indicators of genetic predisposition to disease. Social history is a broad category of the patient's medical history but may include the patients smoking or other tobacco use, alcohol and drug history and should also include other aspects of the patient's health including spiritual, mental, relationship status, occupation, hobbies, and sexual activity or pertinent sexual habits. These may require further questioning if there is a concern for health risk or any relationship to the acute disease state.
Patient allergies are a crucial aspect of history gathering as this may have potentially life-threatening consequences. It is critical to always ask clearly if the patient has any medication allergies and if they do, clarify the reaction they had to the medication.
Medication history is also important as patients take more and more medications and drug-drug interactions must be avoided.
Other areas of the history may be obtained on a case-by-case basis. Age and gender will often guide the interviewer in when to obtain these further histories. Parents of infants should be asked about complications of the pregnancy, delivery, and prematurity. Also, parents of pediatric patients should be asked about the immunization status of the patient. Immunization status for adults and geriatric patients is often relevant. With more vaccination options, this may become a standardized aspect of history taking by practitioners.
Asking female patient's age-appropriate questions about their last menstrual period and their pregnancy history to include gravidity and parity should be common practice. According to the patient's age, further questions about menarche and menopause may be appropriate as part of the medical history.
Issues of Concern
The primary goal of obtaining a medical history from the patient is to understand the state of health of the patient further and to determine within the history is related to any acute complaints to direct you toward a diagnosis. The secondary goal is to gain information to prevent potential harm to the patient during treatment, for instance, avoiding medications to which the patient has an allergy or avoiding administering or prescribing a medication the patient has previously taken and had an adverse reaction.
Often information from the history can direct treatment or may indicate a need for further workup of patient complaints. The history may also inform the provider of certain aspects of the patient's health which will direct care, especially avoidance of potential harm to the patient with regard to allergies or previous treatments limiting care at the time of the encounter.
Family history may help risk-stratify patients with conditions with genetic links.
A key area of concern is the patient's health literacy and how the questions to obtain the histories are asked so the patient understands and can give the appropriate answer. Often patients will not regard their chronic illnesses when asked about “medical problems” especially in acute treatment settings where the patient may not realize the significance or relevance of the chronic disease. In some instances, a question may need to be asked in multiple ways to acquire the necessary information adequately.
Another concern about asking questions of this nature is it may concern the patients about a physician asking personal questions and may withhold information for fear of judgment or legal consequences. Patients should be reassured the information is gathered in an effort to best find the cause of their illness and treat them in the most effective and efficient manner. Once this information has been obtained it should be treated with care for the patients' privacy under laws such as the Health Insurance Portability and Accountability Act (HIPPA) in the United States.
Patient medical history is often a crucial step in evaluating patients. Information gathered by doing a thorough medical history can have life or death consequences. In less extreme cases medical history will often direct care. An example of a patient with a history of breast cancer on chemotherapeutic drugs with a cough may show a need for further workup of a patient with an immunocompromised state versus a healthy patient with no chronic disease.
Documenting the medical history can be lifesaving as well. An encounter with an awake patient who is able to answer all questions which are subsequently recorded on the electronic medical record, could prove to have vital information in the event the patient mental status changes, or during a later encounter if the patient is unable to give their history such as in a traumatic accident.
Those who gather medical history in the acute treatment setting may not have the time or opportunity to gain a complete medical history. In these cases focus should be primarily on the most relevant and pertinent history. If a patient requires emergent treatment such as threats to life, limb or sight, the physician may forgo asking questions about the medical history until after the immediate threats have been addressed and stabilized. Some instances may allow for a few questions, at which time, the 3 primary questions to ask the patient are about the patients general and brief medical history, allergies, and medications the patient is currently or recently has been taking. This information is the highest yield for potentially avoiding the medical error of giving the patient a medication they are allergic to or which may interact with a current medication the patient is taking. The complete medical history may be obtained after the patient has stabilized.
The family may be a potential source of information about a patient's medical history when the patient is unsure or unable to answer questions regarding their medical history. This information can generally be regarded as accurate, but you may have similar issues with the patient's family regarding health literacy and understanding.
Nursing, Allied Health, and Interprofessional Team Interventions
Obtaining a thorough history is important, but the questioning should show empathy to the patient and their condition. Patients may feel rushed or that the provider lacks empathy if questions are asked robotically.
Communicating the patient's medical history to other medical professionals is important and can have significant implications in preventing medical errors. When recording the patient's medical history in the chart, accuracy may reduce medical errors or improper diagnoses. An accurate medical history will cross through all aspects of the interprofessional team involved in the care of the patient.