Medical History Form. History Form 2025

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A comprehensive history intake includes the patients medical history, past surgical history, family medical history, social history, allergies, and medications.
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patients medical history and care across time within one particular health care providers jurisdiction.
The medical record contains valuable information about a patients medical history and individual clinical interactions. It is also a legal document that can serve as evidence of the care provided and discussions with the patient.
The summary must contain information for each injury, illness, or episode and any information included in the record relative to: chief complaint(s), findings from consultations and referrals, diagnosis (where determined), treatment plan and regimen including medications prescribed, progress of the treatment, prognosis
The History and Physical documentation in a patients medical record is completed by a health care provider on admission to a health care agency. It is very similar to the health history obtained by a nurse and is helpful to read when caring for a patient for an overview of their treatment plan.