The Duty To Take A Proper Medical History

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The medical history of a patient is a vital part of a healthcare professional’s assessment of the patient. Understanding a comprehensive picture of the patient’s past health problems helps doctors contextualize new information, and helps doctors identify potential risk factors for disease.

Medical Histories and Maryland Medical Malpractice

Medical histories are important for all doctors, not just the patient’s primary care physician. Good communication with the patient is essential for all doctors; patients who feel comfortable talking with their doctor may be more likely to provide useful information to the doctor about the potential causes of health problems. In fact, doctors are taught that they are more likely to avoid medical malpractice lawsuits if they communicate with their patients because patients who believe that the physician cares are less likely to look to seek compensation if something goes wrong.

Focus On the Patient

Doctors spend years undergoing intense medical training, but doctors also need another type of knowledge in order to provide good services: communication skills. For doctors that spend most of their time interacting with patients, communication skills are essential tools of diagnosis. In order to make a good diagnosis, doctors need to understand symptoms that the patient is experiencing. A strong confidence between the patient and their doctor is the most important feature of a doctor-patient relationship.

Gathering information about a patient’s condition is not as easy as running through a list of medical questions. To ensure that doctors avoid the potential for patient harm and medical malpractice, they must go further. Patients may be uncomfortable or stressed when talking about medical conditions and it is the doctor’s job to relieve this tension.

The consultation helps doctors gain a broad perspective on the patient’s health. Doctors should be able to gain an understanding of the relationship between a patient’s condition and the patient’s health history, lifestyle, risk factors, and social situation. Doctors should also gain knowledge of the patient’s relationship with other healthcare professionals who may currently be treating the patient or who have treated the patient in the past.

The Patient-Physician Relationship in the Consultation

Doctors must learn how to be good listeners so they can help patients paint a realistic picture of their symptoms. To make patients comfortable, doctors should properly maintain all conditions relating to the consultation: the patients should have a private room with a comfortable place to sit, the doctor should introduce themselves and explain the purpose of the visit and should seek consent from the patient to continue. Finally the doctor should listen to the patient before seeking answers to specific questions.

Once the patient has had time to talk freely about their symptoms, the doctor should explore the patient’s symptoms by asking clear, targeted questions. Doctors should watch for non-verbal cues from the patient and help the patient speak freely about their condition. Doctors should explore why the patient is concerned about a condition, what the patient expects from the doctor, and what steps the patient has already taken to alleviate the condition.

Structuring the Consultation

In order to take a successful history of the patient, doctors need to begin the consultation with a clear structure. Doctors should know what kind of information they will need from the patient in order to make a diagnosis, and must work through the patient’s history in a logical progression. Doctors should carefully note all symptoms and concerns from the patient, and should be able to organize and summarize medical findings from the patient’s history.

Guidelines for a Patient History

Often patients are asked to fill out questionnaires before they see the doctor. These questionnaires seek important basic knowledge about the patient’s medical history including:

  • Allergies
  • Previous surgeries
  • Diseases
  • Previous hospitalizations
  • Current and previous medications
  • Patient’s personal and family history of illnesses
  • Use of drugs, tobacco, or alcohol

This information allows doctors to assess the current health plan for the patient and re-evaluate if needed and also permits the doctor to assess interactions with potential medications.

The personal and family health history is very important in the diagnosis process. The patient may not be experiencing any symptoms of a disease, but lifestyle factors or family history could point doctors to a high-risk factor of a disease, which could lead to an early diagnosis and may save a life. The personal and family health history should include information, like the causes of death of immediate family members of the patient, any occupational hazards that affect the patient’s health, the lifestyle factors like smoking or lack of exercise that contribute to the patient’s condition, and non-medical social or financial factors that contribute to the patient’s condition.

Reporting a full medical history is a shared responsibility between the patient and doctor; the patient has a duty to the doctor to share their information, and the doctor has a duty to inquire about the patient’s health background and to properly document it and incorporate the information into the diagnostic process.

When doctors assess patients, they will take detailed notes and gather specific information about symptoms the patient experiences including the:

  • Location
  • Severity
  • Chronology (when it started, worsened…)
  • Circumstance (when does the symptom occur?)
  • Aggravating factors
  • Associated symptoms
  • History of similar symptoms

After talking with the patient, the doctor will begin a full physical examination of the patient and will identify any symptoms the patient missed in the history. Though the physical examination is important, the medical history of the patient should prove more useful to doctors if it is completed correctly.

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