Page 18 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

» Name of the patient

» Date of birth

» Address

» Phone number

» Next of kin or significant other

» Current insurance information

☐ A comprehensive health history (updated annually) which
includes:

» A comprehensive medical history - patient’s past

history of illnesses, injuries and treatments, prior
operations and hospitalizations, current medications,

age-appropriate immunization

» A comprehensive family history - health status or

cause of death of the patient’s family members,

including specific and hereditary diseases that may
place the patient at significant risk

» A comprehensive psychosocial history, with
significant information about the patient’s activities

and other relevant social factors such as:

• Marital status, living arrangements, employment,

level of education

• Use of street drugs or misuse of prescription drugs

• Use of alcohol

• Use of tobacco, including smokeless

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