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Taking and Updating Patient History

A complete and accurate history is the foundation for all patient care. How you collect and record patient information can make a difference in their overall health and well-being.

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.

There are several important points to remember when taking patient history:

  • Ask the patient about changes or additions to the history at each visit. These include any new or discontinued medications, new conditions, new allergies, or changes in socio- or demographic information (e.g., marital status, job status, health status of a family member, or travel outside of the US).
  • 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 areas that are left blank or noted as ‘not applicable.’ 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.

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