history (his'to-re) [Gr. historia, inquiry],
In the health care professions, a systematic record of past events as they relate to a person and his medical background. A carefully taken medical, surgical, and occupational history will enable diagnosis in about 80% of patients. Synonym: medical history
The patient should be given the opportunity to describe his symptoms in his own words, fully, completely, and without interruption. The examiner encourages the patient to speak by maintaining a sympathetic and nonjudgmental attitude. After the patient finishes his explanations, the examiner usually asks carefully chosen questions to elicit details about an illness and to gain deeper insights.
See: nursing assessment
The complete medical, family, social, and psychiatric history of a patient up to the time of admission for the present illness.
A record of all aspects of a person's oral health, previous evaluations and treatments, and the state of general physical and mental health. See: oral diagnosis
family history Abbreviation: FHx
A record of the state of health and medical history of members of the patient's immediate family, which may be of interest to the physician or other health care provider because of genetic or familial tendencies noted.
natural history (of disease)
The expected or predictable course of an untreated illness. The knowledge of the expected course of a disease is usually based on prior study of the effects of the illness on a large group of patients over time. See: disease progression
The first step of the assessment stage of the nursing process that leads to development of a nursing care plan. Valuable information can be obtained from this history, and reactions to previous hospitalization can be recorded and utilized in managing the patient's care during the current stay.
A semistructured interview process used by occupational therapists to determine a person's roles, approach to tasks, and sense of identity.
A medical history of a person's sexual practices, concerns, illnesses, partners, preventive activities, and risk factors for sexually transmitted diseases.