Understanding the Core Components of a Medical History
A medical history, or patient history, is a collection of subjective information reported by the patient to a healthcare provider. This crucial intake process helps clinicians form an accurate picture of a patient's health over their lifetime, identifying trends, risks, and potential links between past events and current issues. A complete medical history typically includes several key sections that cover different aspects of a patient's health journey.
Chief Complaint (CC) and History of Present Illness (HPI)
At the start of an appointment, the healthcare provider will focus on the Chief Complaint (CC), which is the primary reason the patient is seeking care. This is followed by the History of Present Illness (HPI), a detailed account of the CC, including its onset, duration, location, quality, and severity. The HPI is a narrative component that gives context to the patient's current symptoms and helps to narrow down potential diagnoses.
Past Medical, Surgical, and Family History
These sections provide a detailed timeline of a patient's health. The past medical history includes all prior illnesses, injuries, hospitalizations, and major health conditions. The surgical history lists all previous surgical procedures. Family history is a record of health conditions and diseases within the patient's immediate blood relatives, such as parents and siblings, which helps identify genetic risk factors. Documenting this information is critical for identifying hereditary conditions like heart disease or certain cancers.
Social History and Review of Systems (ROS)
The social history captures information about a patient's personal life that can influence their health. This includes lifestyle habits like diet, exercise, substance use (tobacco, alcohol, and illicit drugs), occupation, living arrangements, and travel history. The Review of Systems (ROS) is a comprehensive, head-to-toe inventory of the patient's symptoms or lack thereof. This process systematically covers all body systems to ensure no details are missed that could be relevant to the diagnosis, even if they aren't part of the main complaint.
The Key Distinction: History vs. Physical Examination
While the medical history relies on patient-reported information, the physical examination is an objective assessment performed by the clinician. It involves observing, palpating, percussing, and auscultating the patient's body to find signs that help confirm or rule out a diagnosis. The information gathered during the physical exam is separate from the historical narrative.
Why Vital Signs Are Excluded from the Medical History
The most common answer to the question, "Which of the following is not included in the medical history?" is vital signs. Vital signs—like blood pressure, heart rate, respiratory rate, and temperature—are measurable, objective data points recorded at the time of the examination. They reflect the patient's current physiological status, not their past health experiences. While they are a critical part of a complete medical record, they are documented as part of the physical examination, not the historical intake.
Other Exclusions from the Medical History
Beyond vital signs, other elements are intentionally kept separate from the medical history to maintain focus and confidentiality. Examples include:
- Financial or health insurance information.
- Billing records.
- Legal documents, such as a living will.
- Subjective, unprofessional, or derogatory comments.
- Reflex testing results, as these are part of the neurological assessment during the physical exam.
Separating these elements ensures the medical history remains a clear, factual, and patient-centered account of their health, free from extraneous information that could bias a diagnosis or treatment plan.
Medical History vs. Physical Examination: A Comparison
| Aspect | Medical History | Physical Examination |
|---|---|---|
| Information Source | Subjective, patient-reported | Objective, clinician-observed |
| Scope | Past and current illnesses, conditions, lifestyle, family health | Real-time assessment of physical state |
| Key Components | Chief complaint, HPI, past history, family history, social history, ROS | General appearance, vital signs, systemic exams (e.g., cardiac, respiratory, neurological) |
| Data Type | Narrative, patient statements | Measurements, observations, test results |
| Example | Patient reports a family history of diabetes | Clinician measures patient's blood pressure |
Preparing for Your Medical Intake
For patients, having a clear understanding of your health history can significantly improve the accuracy of your care. Here are some steps you can take:
- Document Key Dates: Keep a timeline of major illnesses, surgeries, and significant health events, including the approximate dates.
- Know Your Family's Health: Gather information about the health conditions of your immediate family members, including their age of diagnosis and any causes of death. The CDC provides a useful tool for tracking this information.
- Create a Medication List: Keep an up-to-date list of all medications, including dosages, both prescription and over-the-counter.
- Consider Your Lifestyle: Reflect on your lifestyle habits, such as smoking, alcohol use, and exercise, as these are important parts of your social history.
- Focus on the Facts: When providing information, stick to the facts and objective observations to help your provider compile an unbiased history.
Conclusion
Knowing Which of the following is not included in the medical history? clarifies the roles of both the patient and the provider in building a comprehensive health record. The patient provides the subjective narrative of their health journey, while the provider contributes objective data through the physical examination. Items like vital signs, which are real-time measurements, belong to the physical exam, not the historical account. This distinction is vital for creating an accurate, unbiased, and complete record that guides effective diagnosis and treatment.
For more detailed information on collecting family health information, you can visit the American Medical Association's guide.
