How to Document a Review of a Patient's Medical History Before Procedures

Learning how to properly record a patient’s medical history prior to any in patient surgical procedures is one of the basic skills operative nurses must master. The history is taken down after the patient has consulted with the surgeon and has undergone a thorough physical exam to prepare for the procedure. Recording the patient’s history helps the operative team understand the conditions or incidents that contributed to the injury. Ideally, the medical history should mention any prior and current conditions, allergies and prescriptions the patient is taking.

Instructions

• 1

  Begin the history with a topic statement. It should mention the patient’s age, sex, race, current medical problems and the reason the patient is undergoing the procedure. According to the Medical Department at Vanderbilt University, a good example of a topic sentence would be as follows: “'Mr. Womack is a 45 yo man with a history of recurrent pulmonary emboli (PE) who presents with chest pain. Two years prior to admission, he suffered a compound femur fracture from a motor vehicle accident. His course was complicated by a PE.”

• 2

  Include a section for “pertinent negatives.” These are negative statements that reflect a differential diagnosis, which weighs the probability of one condition over another. An example, from the Vanderbilt University medical department, is: “…He has not been taking his coumadin over the last three weeks.”

• 3

  Finish your discussion of the patient’s chief complaint by explaining how the patient came to your facility. For example, you might say that the patient endured six months of chiropractic treatment that did not significantly reduce his back pain and that is why he now presents for a lumbar epidural steroid injection.

• 4

  Begin a section related to medications and other prior illnesses. Include allergies to medicine, substance abuse and childhood conditions that seem relevant.

• 5

  Discuss family history. In particular, mention if any member of the patient’s family (deceased or alive) was diagnosed with cancer, diabetes, heart disease or conditions related to the chief complaint.

• 6

  Describe any recent physical examinations or diagnostic tests that doctors use to recommend surgery. For example, a recent MRI showing meniscal tear in the knee might have been the reason for the doctor to recommend a knee arthroscopy.

• 7

  Finish with a section on laboratory data. According to Vanderbilt University’s medical department, you should follow this order: electrolytes, CBC, urinalysis, CXR, EKG, microbiology and other.