What is the proper procedure for collecting a patient's medical history in a hospital setting?

Comprehensive Medical History Collection Protocol in Hospital Settings

The proper procedure for collecting a patient's medical history in a hospital setting should include documenting the patient's story in as much detail as required to retell it, using appropriate documentation techniques while ensuring accuracy and completeness of information.

Core Components of Medical History Collection

• Begin by establishing the patient's identity through proper identification protocols, including surname, forename, date of birth, and hospital unique identification number 1
• Document the patient's chief complaint and history of present illness, which drives the remainder of the examination and decision-making process 1
• Include the patient's narrative in sufficient detail to accurately represent their story, potentially including entries from the patient and other care team members when permitted by regulations 1
• Collect information about duration of chronic conditions, dates of diagnosis, and prior negative tests as part of comprehensive documentation 2
• Document all previous medical conditions, hospitalizations, surgeries, and blood product receipt to establish a complete medical background 2

Specific History Elements to Document

• For cardiac patients, document symptoms such as dyspnea (at rest or on exertion), orthopnea, paroxysmal nocturnal dyspnea, weight changes, swelling, and fatigue, including onset and duration 1
• Record history of chronic conditions including renal disease, lung disease, dementia, depression, liver disease, collagen vascular disease, musculoskeletal disease, and malignancy 1
• Document immunization history, including influenza and pneumococcal vaccinations with dates 1
• Include medication history covering current medications, prescription drugs, over-the-counter medications, and complementary or alternative therapies 2
• Record allergies and intolerances, including dates and types of reactions to prevent adverse events 2

Documentation Best Practices

• Use macros and templates appropriately to improve completeness and efficiency, particularly for standardized terminology like review of systems and physical examination findings 1
• When using previously documented information that remains accurate, employ "review/edit and/or attest, then copy/forward" techniques to improve efficiency while maintaining accuracy 1
• Avoid "copy/paste" of entire notes without editing, as this can propagate factual errors, outdated information, and contradictory data 1
• Indicate the source of data when pulling information from another location in the chart 1
• Document both positive findings and pertinent negatives using clear language 2

Social and Environmental Factors

• Include race, ethnicity, birthplace, residence, and travel history as part of comprehensive documentation 2
• Document health-related behaviors including tobacco, alcohol, and drug use 2
• Record employment history and potential occupational exposures 2

Special Considerations for Specific Populations

• For women, document gynecologic and obstetric history, plans for pregnancy, birth control practices, menstrual history, and mammogram history 2
• For HIV patients, include mode of infection, prior HIV medications, CD4 counts, viral loads, and history of opportunistic infections 2

Patient Monitoring During History Collection

• Monitor vital signs including respiratory rate, pulse, blood pressure, and temperature when collecting history from patients receiving blood transfusions 1
• Be alert to signs of transfusion-associated circulatory overload (TACO) such as acute respiratory compromise, pulmonary edema, tachycardia, and hypertension, particularly in older, non-bleeding patients 1

Common Pitfalls to Avoid

• Failing to document allergies and adverse medication reactions can lead to preventable adverse events 2
• Incomplete vaccination records may result in missed opportunities for preventive care 2
• Overlooking family history can miss genetic risk factors for disease 2
• Creating excessive documentation beyond what is necessary for patient care, quality measurement, and compliance with appropriate coding requirements 1

Documentation Training and Support

• Provide effective and ongoing EHR documentation training for clinical personnel to optimize system use 1
• Implement additional training with every system upgrade to maintain documentation quality 1
• Develop institutional "chart etiquette" principles and policies based on well-defined standards 1