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Detailed characterization of the patients current problem in paragraph form. Include all aspects of the HPI. The history should be described in chronological order. Past Medical History (PMH): Whereas the HPI is recorded in paragraph form, it is important to keep the PMH in list form, and brief.
This form helps gather comprehensive information about a patients past and current health status, family medical history, lifestyle factors, and any other relevant details necessary for accurate diagnosis and effective treatment.
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.
It provides the full picture of a patients health so you can understand their medical background, family medical history, potential risk factors, and current health status thoroughly.
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.
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A comprehensive history intake includes the patients medical history, past surgical history, family medical history, social history, allergies, and medications.

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