Medical History

Issues of Concern

Biases in History-Taking

The following principles, originally derived from the approach to neurocritical patients, are applicable to all history intakes to address biases.

• Anchoring: Focusing on one aspect of medical history when new information is available.
• Availability: Based on available information, deeming a diagnosis more or less likely.
• Premature closure: Narrowing on a diagnosis before completing a thorough workup.
• Representativeness restraint: Forcing all history into one pattern of clinical presentation.
• Unpacking principle: Focusing on some aspects of workup and omitting others before arriving at a diagnosis.
• Context errors: Considering all parts of medical history equally relevant.[11]

The primary goal of obtaining a medical history from the patient is to understand the patient's state of health and determine whether the history is related.[1] The secondary goal is to gather information to prevent potential harm to the patient during treatment. Focusing on these goals in the context of recognized biases and colleague feedback reduces diagnostic errors.

Health Literacy

A key concern is ensuring patients understand questions and can provide accurate histories based on their health literacy. Patients may not consider their illnesses relevant when asked about medical problems, especially in acute treatment settings. Sometimes, a question may be asked in multiple ways using colloquial rather than medical terms. When encountering language barriers, the best practice approach is to use the facility-provided language service but not limit the intake level. Clinicians have approaches to hand-off between nurses, nurse practitioners, physician assistants, and physicians so that important aspects of history are communicated.[12][13][14]

Health Insurance and Portability and Accountability Act

Patients may withhold information due to fear of judgment or legal consequences. Patients should be reassured that the information is gathered to find the root cause of their illness and treat them most effectively and efficiently. Once obtained, this information must be handled with utmost care to ensure patients' privacy in accordance with laws such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States. This law prohibits the unauthorized sharing of health information. 

Use of Mobile Applications and Artificial Intelligence 

The use of mobile applications and artificial intelligence–driven programs is at the heart of current discussions regarding workflow. The results of current studies recommend that these tools enhance the workflow rather than substitute the clinician's role for conducting a standardized medical history. If the question set is too large, results demonstrate that the history does not accurately match the defined purpose, such as the patient's chief complaint.[15][16][17]

Clinical Significance

The medical history is brief or expanded depending on the scope of a medical visit. If a patient presents for an annual wellness visit, the history should encompass all aspects of the patient's history. If the patient has an established relationship with the clinician or is arriving for a procedure such as cyst removal or pap smear, the history does not need to include all standardized aspects. In procedural, surgical, or progress visits, the medical history is more tailored to the visit.

Focused History

A focused history is utilized in urgent care or emergency settings. Instead of extensively analyzing every detail of the patient's illness history, such as events that may have occurred years ago, the focus is on understanding the immediate context of the visit. This approach includes any changes that have occurred since the last visit and the long-term outlook. This approach is similar to the practice in some primary care visits, where the emphasis is placed on addressing the patient's immediate needs and providing timely care. For example, a patient with a history of breast cancer on chemotherapeutic drugs with a cough versus a healthy patient with no chronic disease. Although the clinician has access to the entire medical history, questions should remain focused on the chief complaint of cough and not delve into cancer management plans. Similarly, if a patient presents with altered mental status and can no longer provide a history, looking into previous admissions or speaking to the admitting team for relevant information is more appropriate. A detailed history may not be as relevant as the accident the patient just emerged from or a previous history of stroke. Clinicians tailor the physical examination to address aspects pertinent to the patient's clinical complaint and the focused history. For example, in cases of difficulty breathing and a history of asthma, emphasis is placed on conducting a thorough lung examination, possibly omitting other parts of the physical examination.

Expanded History

Complete medical histories may be obtained after the patient has stabilized or if the patient presents for a visit requiring a thorough history. The family members or caregivers may be a potential source of information about a patient's medical history when the patient is unsure or unable to answer questions. The same patient in cancer treatment could be asked about changes in sleep, appetite, vaccination status, partners, or additional details to tailor a treatment plan, including changes in medication regimen and lifestyle recommendations. In such cases, the treating clinician may continue to discuss different treatment options. Some clinicians may consult with specialists to gain further medical insights and maintain continuity of care. Typically, a review of systems and physical examinations includes all systems.

Nursing, Allied Health, and Interprofessional Team Interventions

Although obtaining a detailed history is crucial, it is equally important for clinicians to approach the questioning process with empathy and consideration for the patient's feelings and condition.[18] Patients may feel rushed or uncomfortable if questions are asked in the same order using the exact words as learned during educational contexts. By adapting the questioning style to accommodate each patient's individual needs and preferences, clinicians can create a more comfortable and engaging environment for communication. This approach not only enhances the quality of information gathered but also enables clinicians to develop their values and skills in patient-centered care.

Furthermore, effective communication of the patient's medical history to other healthcare professionals is essential for ensuring continuity of care and preventing medical errors. Hand-off protocols between healthcare teams serve as crucial checkpoints for transferring patient information accurately and comprehensively. Each healthcare facility has a standardized checklist, which may include reviewing key aspects of the patient's medical history, such as diagnosed conditions, past surgical procedures, and current medication lists. By adhering to these protocols, healthcare professionals can facilitate smooth transitions of care, minimize the risk of oversight or miscommunication, and ultimately promote better patient outcomes.

Nursing, Allied Health, and Interprofessional Team Monitoring

Various members of an interprofessional healthcare team, including technicians, nurses, advanced clinicians, physicians, and specialists, play integral roles in gathering different components of a patient's medical history. As each interprofessional team member is involved in coordinated care, communication is essential to ensure that the same intake is not repeated or that crucial pieces of the medical history are missed. Some aspects of the medical history are best obtained at triage, whereas the surgeon or pharmacist may more appropriately address other aspects. Understanding the scope of practice is crucial for conducting clinical intake effectively, leading to the next step in a medical visit.