Which element of the medical history includes information gathered from patients and non-patients?

Get certified with the Cardiovascular and Thoracic Surgery Coder Test. Enhance your career with comprehensive flashcards and multiple choice quizzes that offer in-depth explanations. Prepare effectively for success!

The element of medical history that includes information gathered from both patients and non-patients is known as "additional history." This component encompasses supplementary data that can be relevant to a patient's current health status but may extend beyond the direct clinical encounter. It allows medical professionals to capture a broader context of the patient's circumstances, including insights from family members, caregivers, or any other significant individuals who can provide valuable information about the patient's health history, lifestyle, or social determinants of health.

In contrast, past medical history primarily focuses on the patient's own prior health issues, treatments, and surgeries. Social history is specific to aspects of the patient’s lifestyle that might impact their health, such as occupation, tobacco use, and alcohol consumption, and typically relies on the patient's own insights. The review of systems involves a systematic approach to identifying symptoms across various organ systems primarily from the patient’s current complaints. Thus, additional history stands out as the component that emphasizes the inclusion of information from a wider circle around the patient.

Subscribe

Get the latest from Examzify

You can unsubscribe at any time. Read our privacy policy