The Importance of a Medical History as it Relates to Patients Injured in Accidents
- Posted on: Apr 1 2015
The medical history of a patient is information gained by a qualified accident physician by asking specific questions, either of the 
patient or of other people who know the person and can give suitable information with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patients are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of the medical personnel. The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan.
Dr. Jeff J. Mollins, practicing for over 25 years in downtown Brooklyn, is an expert in the diagnosis, treatment, and documentation of patients injured in accidents. When it comes to patients injured in accidents (whether it is an automobile accident, work accident, slip and fall, or construction accident), a clear, concise, accurate history is extremely important. Dr. Mollins will ALWAYS take a detailed medical history on every patient he examines that has been injured in an accident.
Dr. Mollins typically asks questions to obtain the following information about the patient:
1. Identification and demographics: name, age, height, weight.
2. The “chief complaint”-the major health problem or concern and its time course.
3. History of the present illness-details about the complaints.
4. Past medical history-including major illnesses, previous accidents, previous surgery, any current ongoing illnesses.
5. Review of systems-systemic questioning of different organ systems.
6. Family diseases-especially those relevant to the patient’s chief complaint.
7. Social history-including living arrangements, occupation, marital status, number of children, drug use, recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.
8. Allergies-to medications, food, latex, and other environmental factors.
9. Sexual history
Dr. Mollins is aware that when it comes to accidents, knowing the mechanism of how that accident occurred is extremely important. Dr Mollins will always ask the patient to specifically describe the accident. By understanding the mechanism of the accident, Dr. Mollins will then have better insight as to what the particular injuries may be. He can also determine the liability (whose fault is is!) of the accident and if the injuries sustained are a direct result of the specific accident. Another important factor is to find out is if the patient has had any previous accidents, when that accident occurred, what was the treatment, and have those injuries resolved. This again goes to finding out if the injuries sustained are causally related to this accident (not the previous one).
Taking an accurate history is extremely important in determining a proper diagnosis. Dr. Mollins can then place his patients on a comprehensive treatment regimen so they may achieve wellness as expeditiously as possible. Also, a precise history can also provide concise documentation which is essential when treating patients involved in accidents.
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