Clinical exam · History taking and the interview
The clinical history: its parts and their order !
- History
The clinical history is the ordered record of what the patient tells, what the examiner finds and what is decided.
Updated 2026-11-01
What it is
The clinical history is the document where the patient's health and the care team's actions are recorded in chronological order. In Colombia it is a private, mandatory and confidential document. Its classic order runs from what the patient reports (the history) to what is observed (the physical exam) and ends with the reasoning (assessment) and the decisions (plan). Writing it well is the basis of every diagnosis.
What it must include
- Identification: full name, ID, date of birth, age, sex, marital status, occupation, residence, phone, companion, responsible person and insurer.
- Source and reliability of the information: the patient, a relative or previous records.
- A brief chief complaint in the patient's words.
- Present illness in chronological order, with pertinent negatives.
- Past personal history (medical, surgical, medicines, allergies, substance use, trauma, transfusions, gynaecologic-obstetric, immunisations) and family history.
- Review of systems, physical exam (vital signs first), assessment with differential diagnoses, and plan.
How to ask
- Identification: 'Could you confirm your full name, ID number and date of birth?'
- Chief complaint: 'What brings you here today?' Recorded in the patient's words, in quotation marks.
- Present illness: 'Tell me from the beginning: when did it start and how has it changed?'
- Past history: 'What illnesses, operations, hospital stays or allergies have you had? What medicines do you take?'
- Family history: 'Has anyone in your family had diabetes, high blood pressure, heart attacks or cancer?'
- Review of systems: 'Now I'll ask some quick questions about the rest of your body, even if they seem unrelated.'
- Physical exam, then assessment and plan, explained to the patient in plain words.
Test yourself
Think of the answer, then tap the question to see it.
What are the parts of the clinical history in their classic order?
Identification, chief complaint, history of present illness, past personal and family history, review of systems, physical exam, assessment and plan.
Which Colombian regulation governs the clinical record?
Resolution 1995 of 1999 of the Ministry of Health, which defines it as a private, mandatory and confidential document.
Which five characteristics does that resolution require of the clinical history?
Completeness, chronological sequence, scientific reasoning, availability and timeliness.
Why should abbreviations be avoided in the clinical record?
Because the regulation requires a clear, legible record; an abbreviation can be read in more than one way and lead to errors in care.
Related
- The medical interview: rapport, open questions and listening
- Chief complaint and history of present illness
- Past medical, surgical, family and social history
- Review of systems
- From findings to diagnosis: problem list, differential and SOAP note
- Vital signs: what they are and how to record them
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Resolución número 1995 de 1999 (julio 8): por la cual se establecen normas para el manejo de la Historia Clínica (Ministry of Health (Colombia), 1999); 12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024).
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Representative model, for educational purposes only.