HEALTH EVALUATION: HISTORY AND PHYSICAL EXAMINATION
Routine health care involves a detailed history and physical examination. Routine visits are also a good time to counsel pa-tients about issues that affect health care and to perform routine screening tests based on age and risk factors..
A comprehensive medical record should be kept and maintained for each patient and updated periodically. This record includes a medical history, physical examination, and laboratory and radiology results. Information from re-ferrals and other medical services outside the purview of the obstetrician–gynecologist should be integrated into the medical record. The American College of Obstetricians and Gynecologists (ACOG) offers a form called the ACOGWomen’s Health Record to assist health care providers intheir daily practice (Appendix A). It also includes screening recommendations and coding information.
Information contained in the medical history includes dis-cussion of the chief complaint, history of present illness, review of systems, and a medical history that includes a gynecologic history, obstetric history, health history, and social history.
· Chief complaint is a concise statement describingthe symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter. A chief complaint may not be present if the patient is seeing the obstetrician–gynecologist for preventive care. History of present illness is a chronologic description of the development of the patient’s present illness.
· Review of systems is an inventory of body systems, ob-tained through a series of questions, which seeks to iden-tify signs and symptoms that the patient has experienced or is experiencing.
· Past, family, and social history consists of a review ofgeneral medical, obstetric, and gynecologic history; fam-ily health history; allergies; current medications; and sexual and social history.