NRGI Detailed patient past medical history.xlsx 2025

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OLD CARTS is a mnemonic device used by providers to guide their interview of a patient while documenting a history of present illness. The letters stand for onset; location; duration; characteristic; alleviating and aggravating factors; radiation or relieving factors; timing; and severity.
This personal information includes details such as: The patients medical history. Applicable diagnoses. Historical and ongoing medications, including over-the-counter and alternative treatments. Past medical and surgical interventions. Immunization status.
Categories included in past medical history include current health, medications, childhood illnesses, chronic illnesses, acute illnesses, accidents, injuries, and obstetrical health for females.
Explanation: A detailed assessment of a patients medical history is easily viewed in the problem list. The problem list is a comprehensive collection of a patients issues, which includes current, ongoing, and past illnesses, as well as any other major patient concerns.
Past Medical History: Start by asking the patient if they have any medical problems. If you receive little/no response, the following questions can help uncover important past events: Have they ever received medical care? If so, what problems/issues were addressed?
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Create a Checklist Greet patients and introduce yourself. Ask why the patient is being seen. Inquire about previous medical and surgical history. Ask about allergies and current medications. Request information about family medical history. Ask about social history, as well as smoking and drinking.
The primary goal of obtaining a medical history from the patient is to understand the patients state of health and determine whether the history is related. [1] The secondary goal is to gather information to prevent potential harm to the patient during treatment.

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