A universal Pre-History is a sheet of paper listing the standard questions that will be asked of you during a typical office visit. “When did your problem start?” “What makes it better or worse?” are examples.
While in the office with your medical provider, it is often difficult to keep your thoughts organized. Many patients remember details while driving home from a visit. Using a Pre-History allows you to organize your thoughts in advance of the examination room.
Federal law from the 1990’s anticipated electronic health records (EHR’s) and foresaw a day when you could review your records for content and accuracy. They also established your right to amend records. We promote the use of a Universal Pre-History so you can describe your problems within the format of the EHR.
We have organized methods so that your medical office will put the content of your pre-history into your medical record – before the doctor enters the room with you. This ensures that your story is documented with hopes that your doctor will better understand your problem. We believe this will result in a better directed physical examination and a more precise diagnosis and treatment plan.
From a healthcare point of view, a medical encounter is divided into three key components: History, Exam, Medical Decision Making. The History component involves documentation regarding your chief complaint and details about it. By using a pre-history, you are “co-authoring” your medical record.