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Foundation for Future Patient Care: A Patient's History

A complete and accurate history is the foundation for all future patient care - whether preventive care, diagnosis and treatment of acute or chronic illness, or prescription of medication.

In spite of all of the technology available today, the history is still the mainstay of diagnosis. The impact of social, environmental, hereditary and behavioral factors on patient well-being and illness must be realized in the patient’s history

The accuracy and completeness of the information contained in a patient’s history is essential for optimal patient care. A complete and accurate history is the foundation for all future patient care—whether preventive care, diagnosis and treatment of acute or chronic illness, or prescription of medication.

Important Points to Remember

Ask the patient about changes or additions to the history at each visit, including:

  • New or discontinued medications
  • New conditions
  • New allergies
  • Changes in socio- or demographic information:
  • Marital status
  • Job status
  • Health status of a family member
  • Travel outside of the U.S.

Pay particular attention to changes in medications and be aware that patients may be seeing other providers who are also prescribing medications or therapies. Drug-to-drug interactions are a significant cause of patient morbidity and mortality and medical malpractice actions against the prescriber. Any changes should be brought to the physician’s attention.

Carefully review any initial history obtained by staff to clarify, confirm and elicit more details to address any blank or “N/A” areas. The physician is ultimately responsible and should regularly review the information gathered, especially when the patient displays a confusing clinical presentation.

Be aware that physicians are still accountable for knowing the information in the patient’s chart.

Additional Resources

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