Hone

Lessons · Medicine foundations · taking a history in the standard order

A history in the standard order

Presenting complaint, then the history of that complaint, then past medical history, then drugs, then allergies, then family history, then social history.

Hone is a place to practise a career, one idea a day. This is one of its lessons, written out in full and free to read without an account.

What it is for

Two things are happening at once. The person tells their story, and you build a document somebody else will read in a hurry at three in the morning. The order is what makes the second one possible, because every reader knows exactly where to look for the allergies.

How to think about it

Keep the order even when the conversation does not. People answer the question after next, and that is fine; write it in its place. Say the headings in your head as you move, and notice when one has been skipped rather than discovering it at the end.

Worked example

Presenting complaint: what brought them, in their own words
Their sentence, not yours, and short.
History of the presenting complaint: when, how, what changed it
The story of this one thing, in time order.
Past medical history: what has happened before
Conditions, operations, admissions.
Drug history: what they take, how much and how often
Including anything bought without a prescription.
Allergies: what happened, not just the name
A rash and a swollen throat are different records.
Family history: what runs in the family
Who, and at what age.
Social history: home, work, who is at home, what they can do
The part that decides what is actually possible for this person.

Your turn

After presenting complaint, history of the presenting complaint and past medical history, write the heading that comes next.

Presenting complaint, history of it, past medical history, then  history.

The trap

Letting allergies drift to wherever they came up in the conversation. It is the heading a reader looks for first and the one they must not have to hunt for, so it keeps its place in the written order however the conversation went.

Practise taking a history in the standard order on HoneA question on it now, a coding challenge where there is one, and it is remembered for review. Free, no email needed.