FAQs

If the patient can give a current history, should I review prior medical records?

Yes.

Reviewing prior medical records as part of a current office visit is good patient care. The patient should be asked to describe not only the current complaint (i.e., "what brings you to the office today?" or "this is your follow-up visit after...") but any concerns that may have led up to the current visit. With one or two skillful questions, you can ascertain what is troubling the patient. With an opportunity to talk (uninterrupted) for several minutes, the patient can relate a significant amount of useful information, and feel that you are listening.

However, relying only on the patient's memory is risky. For example, a patient may have presented over a period of time, with a series of symptoms that--taken one at a time--have been managed appropriately, but all together may indicate a much more severe condition. Review of the past records is necessary to put those pieces together. In addition, a review of the record can refresh your memory about pending test results, the need for routine screening, results of referrals to specialists, or other matters that should be addressed.