::::Instant Medical History::::

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Instant Medical History

Click here for an overview of the Instant Medical History with Dr. John Bachman from the Mayo Clinic. To access the Instant Medical History Demo, click here.

Instant Medical History is patient interview software that organizes patient concerns and begins the subjective history before the encounter. Patients respond to multiple choice questions that branch based on their responses. Enabling patients to enter the data to populate the subjective portion of the medical record makes the encounter time more efficient. Both the patient and the doctor are focused on the health concerns presented at the start of the encounter.

In the background, the software translates the interview summary into clinical terminology and organizes the positives and negatives according to the pertinent organ system, before passing the details to an Electronic Medical Record. With this information in advance, physicians can quickly review the information and conduct a more efficient and informed patient interview, reducing the patient office visit time by 3-4 minutes while increasing the documentation quality significantly.

A sample output of the Instant Medical History:

Mar 28, 2004 10:07 AM

J. Arthur Gleiner, MD

Chief Complaint

Shawn Sample is a 30 year old male. His chief complaint is "cough".

History of Present Illness

He reported: cough productive of sputum, dyspnea, wheezing, symptoms present for 4 to 7 days, recent coryza

Severity: He reported: continuous cough, exertional dyspnea severe, sputum increasing in quantity, more than 30 cc sputum in 24 hour.

Duration: He reported: cough for 1 week.

Timing: He reported: recent onset cough, nocturnal cough.

Context: He reported: pleuritic chest pain, exertional dyspnea.

Associated Signs and Symptoms: He reported: yellow or green sputum, brown sputum, foul smelling sputum

Past, Family, and Social History

Past Medical History

History of chest radiograph less than 1 year ago,

Social History

Tobacco Use

History of: smoking cigarettes.

Review of Systems

Constitutional

He reported: night sweats, fever in the past week.

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