Essential Components of Past Medical History Documentation

Core Medical History Elements

The American College of Physicians recommends including duration of any chronic conditions, dates of diagnosis, and prior negative tests in past medical history documentation 1
The Infectious Diseases Society of America suggests documenting all previous medical conditions, hospitalizations, surgeries, and blood product receipt 1, 2
The Centers for Disease Control and Prevention recommend including history of infectious diseases, including HIV-related conditions, opportunistic infections, and sexually transmitted diseases in past medical history documentation 1
The American Medical Association advises documenting prior medication use, including specific drugs, duration of therapy, complications, side effects, drug resistance, and adherence 1, 3
The American Heart Association recommends including comorbidities and risk factors for conditions such as coronary heart disease, dyslipidemia, diabetes mellitus, kidney disease, and osteoporosis in past medical history documentation 1, 2

The National Institutes of Health suggest documenting current medications, including prescription drugs, over-the-counter medications, and complementary or alternative therapies 1, 3
The American Academy of Allergy, Asthma, and Immunology recommend including allergies and intolerances, including dates and types of reactions in past medical history documentation 1, 3
The Centers for Disease Control and Prevention advise documenting vaccination history, including childhood vaccinations, adult boosters, and travel immunizations 1, 3

The American College of Physicians recommend including race, ethnicity, birthplace, residence, and travel history in past medical history documentation 1, 4
The National Institutes of Health suggest documenting health-related behaviors, including tobacco, alcohol, and drug use 1, 4, 3
The American Medical Association advises including employment history and potential occupational exposures in past medical history documentation 1, 4

The Infectious Diseases Society of America recommend including mode of infection, prior HIV medications, CD4 counts, viral loads, and opportunistic infections for HIV patients 1
The American College of Obstetricians and Gynecologists suggest documenting gynecologic and obstetric history, plans for pregnancy, birth control practices, menstrual history, and mammogram history for women 1

The American Medical Association recommends including pertinent negatives, using clear language, and documenting the source of information in past medical history documentation 3, 4
The National Institutes of Health advise documenting information about the patient's literacy and primary language 4

The American College of Physicians warn that failing to document allergies and adverse medication reactions can lead to preventable adverse events 1, 3
The Centers for Disease Control and Prevention recommend avoiding incomplete vaccination records, which may result in missed opportunities for preventive care 1
The American Heart Association advise against overlooking family history, which can miss genetic risk factors for disease 1, 4