From the Guidelines
A patient's medical history is considered to contain both objective and subjective information, with objective elements including verifiable facts and subjective elements comprising the patient's reported symptoms and personal experiences. When evaluating a patient's medical history, it is essential to consider both the objective and subjective components to develop an appropriate care plan. The objective components, such as previous diagnoses, laboratory results, and medication lists, are factual pieces of information that can be independently confirmed, as outlined in the refractive errors preferred practice pattern 1.
In contrast, the subjective components, including the patient's reported symptoms, pain levels, and personal experiences with illness, rely on the patient's perception and cannot be independently verified by the healthcare provider. According to the study 1, a thorough history may include items such as the patient's self-assessment of visual status, visual needs, and any recent or current visual symptoms, which are subjective in nature.
Key elements of a patient's medical history include:
- Demographic data
- Chief complaint and history of present illness
- Ocular symptoms and history
- Systemic history, including medical conditions and previous surgery
- Medications and allergies
- Family and social history
- Directed review of systems, as noted in 1.
By considering both the objective and subjective aspects of a patient's medical history, healthcare providers can gain a comprehensive understanding of the patient's health status and develop effective care plans that address their unique needs.
From the Research
Patient Medical History
A patient's medical history is considered a crucial aspect of the diagnostic process. The information gathered from a patient's medical history is:
- Used to inform diagnosis and treatment 2
- A core determinant of a medical diagnosis 3
- Essential for making an accurate diagnosis 4
Objective or Subjective Information
The patient's medical history can be considered subjective information, as it is based on the patient's account of their health issues and medical experiences. However, the process of gathering this information is structured and flexible, involving active listening, empathetic communication, and cultural sensitivity 2.
Importance of Medical History
The importance of taking a comprehensive patient history is highlighted in several studies, including:
- A step-by-step process for taking a comprehensive patient history 2
- The use of effective medical interviewing skills to gather accurate information 3
- The application of clinical reasoning to filter information and form a provisional diagnosis 4
- The importance of using the patient history and physical as a basis for selecting relevant diagnostic testing 5
Key Considerations
Key considerations when taking a patient's medical history include: