medical history
Enable an AI agent to recognise a person's medical history, assess its relevance and reliability, and determine how it may be collected, reconciled, summarised or shared.
Research draft, second pass
A second pass drafted this model: the structure a model of this thing needs, and what is known about it in the world. The line under this one says how the second half was obtained - researched against sources, or recalled without web access, in which case nothing here was read anywhere and every claim is a lead to verify. Unreviewed either way.
recalled by Codex without web access - no source was read
Researched by: Codex
Purpose and description
Enable an AI agent to recognise a person's medical history, assess its relevance and reliability, and determine how it may be collected, reconciled, summarised or shared.
A medical history is a structured account of a person's past and present health, relevant family and social circumstances, and previous care, assembled to inform clinical assessment and management.
It can be Elicit missing historical information through questions appropriate to the stated care purpose.; Construct a chronology that preserves approximate dates, sources and unresolved discrepancies.; Reconcile overlapping accounts while retaining disagreements and correction trails.; Produce a purpose-specific summary with visible uncertainty and links to supporting material.; Flag information requiring authorised clinical review, such as conflicting medication or allergy accounts.; Prepare an authorised disclosure limited to the relevant history and applicable access constraints..
Distinguishing features
Contains attributed information about a person's health over time; it is not the person's health state itself.
Can contain patient recollections, caregiver accounts and documentary evidence without treating them as equally verified.
Can be elicited or updated during an encounter but remains distinct from the activity of interviewing.
Usually forms part of a medical record but does not encompass every clinical, financial or administrative record artifact.
Includes family and contextual information only through its relevance to the subject's history, without making relatives' records part of the subject's own.
Scope
+ Reported and documented illnesses, injuries, procedures, hospitalisations and their chronology
+ Historical and ongoing medication use, allergies and adverse reactions
+ Family health history and personally relevant social, occupational and exposure history
+ Attribution, corroboration, contradictions, missing information and corrections
+ Purpose-specific summaries and permissions governing access, amendment and disclosure
- The person's actual physiological state and diseases as entities
- The clinical interview or history-taking encounter as an activity
- The complete medical record, including its full collection of images, orders, billing and administrative material
- Diagnosis, treatment selection and prescribing decisions
- Relatives' complete medical histories and independent patient records
Characteristics
- History subject
- Link to the person whose history is represented, with identity-matching status Prevents another person's events or disclosures from being attached to this history.
- Account purpose
- Longitudinal overview, encounter history, specialty history, emergency summary or other specified purpose Determines which omissions are material and which details belong in a summary.
- Temporal coverage
- Known or approximate covered periods, gaps and last review date Distinguishes an outdated or partial account from one reviewed for the present purpose.
- Assertion attribution
- Links each assertion to its informant or document, recorder and recording time Allows an agent to explain who supplied a claim and trace later corrections.
- Evidence status
- Reported, document-supported, disputed, entered in error or unresolved, with supporting references Prevents recalled or contested information from silently becoming an established clinical fact.
- Historical event timing
- Exact date, date interval, approximate age, relative sequence or unknown Supports useful chronology without manufacturing precision.
- Domain coverage
- For each topic: information present, explicitly denied, unknown, not asked, declined or unavailable Separates an explicit negative history from absence of documentation.
- Use restrictions
- Applicable access, purpose, disclosure and amendment constraints with their authority Determines which operations an agent is authorised to perform.
Also called
Where this came from
wikidata · CC0 1.0
Drafted structure
Bundle to layer to finding to question, as the second pass will find it: 6 bundles · 11 layers · 18 findings · 29 questions.
Subject and historical scope Identifies whose history this is and the clinical purpose and periods it represents.
A medical history is interpretable only when its subject, intended use and coverage are clear.
Subject and account boundary
Separates the history subject from informants and linked relatives.
Patient and informant separation
Represent the patient independently from anyone supplying information about them.
- Whose health circumstances does this account describe, and how was that identity established? definition
- Who supplied each portion, and what relationship do they have to the patient? provenance
Purpose and coverage
Makes the intended clinical use and limits of historical coverage explicit.
Purpose-relative completeness
Assess coverage against the account's purpose rather than asserting universal completeness.
- Is this a longitudinal account, an encounter-specific history or a specialty-focused extract? boundary
- Which life periods and health topics were reviewed, and which remain unexamined? measurement
Health events and course Organises illnesses, injuries, procedures and care episodes into an attributed chronology.
The timing and course of prior health events distinguish a medical history from an undifferentiated list of conditions.
Conditions and episodes
Represents what reportedly happened without converting every report into a confirmed diagnosis.
Event identity and status
Distinguish symptoms, reported diagnoses, injuries, procedures and hospitalisations, including their stated outcomes.
- Does this entry describe a symptom, a diagnosis, an injury, a procedure or a care episode? definition
- Who described its outcome or ongoing status, and when was that status last reviewed? provenance
Chronology and recurrence
Preserves event order, timing uncertainty and distinctions between repeated episodes.
Historical time resolution
Keep event dates separate from documentation dates and avoid merging distinct recurrences.
- When did the event occur, at what precision, and when was it documented? measurement
- Do these accounts describe the same episode, a recurrence or events whose relationship is unresolved? boundary
Medications and reactions Captures historical treatment exposure and reported allergies or adverse reactions.
These parts of medical history require distinctions between intended treatment, actual use and the nature of reported reactions.
Medication exposure
Describes reported medication use over time and its relationship to prescriptions.
Prescribed versus taken
Separate evidence of prescribing from accounts of actual use, discontinuation and response.
- What medication, dose, route and use period are known, and which details are uncertain? measurement
- Does the source establish a prescription, dispensing, administration or the patient's report of taking it? provenance
Allergies and adverse reactions
Preserves reaction details and the basis for their classification.
Reaction description and review
Retain the reported substance, manifestations and timing without independently reclassifying a reaction.
- What substance and reaction were reported, including timing and described severity? measurement
- Who classified or reviewed the reaction, and what discrepancies require authorised clinical review? action
Family and life context Represents relevant familial patterns and personal circumstances with explicit attribution and limits.
Medical history extends beyond diagnosed conditions while requiring care not to infer the patient's condition from contextual information.
Family health history
Records reported health events in relatives through their relationship to the patient.
Relative and condition attribution
Keep relatives' reported conditions distinct from patient diagnoses and inferred inherited risk.
- Which relative or relationship is associated with the reported condition, and is age at onset known? measurement
- Is the information recalled, documented, unavailable or deliberately undisclosed? provenance
Social and exposure history
Captures relevant circumstances such as occupation, living conditions, substance use and exposures.
Context with time and relevance
Record contextual information with its period and stated relevance, avoiding unsupported causal claims.
- Which circumstance or exposure is relevant to this history's purpose, and during what period? boundary
- What frequency, duration or amount was reported, with what units and uncertainty? measurement
Evidence, maintenance and use Controls how historical assertions are assessed, corrected and used.
Repeated copying can obscure uncertainty, while sensitive historical information requires explicit authority for access and disclosure.
Assertion quality and reconciliation
Tracks source dependence, missingness, disagreements and corrections.
Traceable historical assertions
Preserve assertion origins and distinguish independent corroboration from copied repetition.
- Which original account supports this assertion, and do later records merely copy it? provenance
- Does an apparent gap mean explicitly denied, unknown, not asked, declined or unavailable? definition
- How should a disputed or erroneous assertion be corrected while retaining its amendment trail? action
Authorised summary and disclosure
Determines permitted operations and preserves meaning in extracts.
Purpose-bound history use
Associate access and disclosure decisions with applicable authority, recipients and purpose.
- What applicable authority and restrictions govern this agent's access, amendment or disclosure? action
- Which details may be included for this recipient and purpose while preserving material uncertainty and source attribution? action
Evidence and external alignment What the world already says about this thing, gathered so the model can be checked against it.
A model that cannot be lined up against existing standards, identifiers and practice cannot be adopted by anyone who already uses them.
Reported evidence
Findings from the breadth pass, kept separate from the structural claims.
Check these first
Recalled without web access and unsourced; every item is a lead to verify.
- The intended sense is inferred to be patient health history as information, rather than history taking or the history of medicine.
- Listed kinds are commonly distinguished components and may overlap rather than form exclusive categories.
- Standards are named from recall; applicable editions, implementation profiles and jurisdictional requirements require verification.
- Which of these check these first hold for the sense of medical history this model covers, and on what evidence? provenance
Kinds and varieties
Recalled without web access and unsourced; every item is a lead to verify.
- History of the present illness
- Past medical and surgical history
- Medication history
- Allergy and adverse reaction history
- Family health history
- Social and occupational history
- Which of these kinds and varieties hold for the sense of medical history this model covers, and on what evidence? provenance
Identifiers and schemes
Recalled without web access and unsourced; every item is a lead to verify.
- Medical record number - Locally assigned identifier - Links the history to a patient within an organisation; it does not uniquely identify the history itself across organisations.
- SNOMED CT - Numeric concept identifier - Can encode clinical concepts recorded in a history; it is not an identifier for the complete account.
- Which of these identifiers and schemes hold for the sense of medical history this model covers, and on what evidence? provenance
Standards and regulation
Recalled without web access and unsourced; every item is a lead to verify.
- HL7 Clinical Document Architecture (CDA), issued by Health Level Seven International, supports structured clinical documents containing history information.
- HL7 FHIR, issued by Health Level Seven International, supports exchange of information such as conditions, procedures, allergies and family history.
- ISO 27269, International Patient Summary, issued by the International Organization for Standardization, specifies a core patient summary that includes relevant historical information.
- Which of these standards and regulation hold for the sense of medical history this model covers, and on what evidence? provenance
Real-world use
Recalled without web access and unsourced; every item is a lead to verify.
- Informing differential diagnosis and selection of investigations.
- Identifying medication exposure, allergies and previous adverse reactions.
- Supporting continuity of care between clinicians and organisations.
- Assessing familial, occupational and behavioural risk factors.
- Planning treatment in light of previous conditions, procedures and responses to care.
- Which of these real-world use hold for the sense of medical history this model covers, and on what evidence? provenance
Failure modes and hazards
Recalled without web access and unsourced; every item is a lead to verify.
- Omissions, recall errors or communication barriers produce an incomplete account.
- Information is attributed to the wrong patient.
- Copied or outdated entries perpetuate errors and obscure changes.
- Patient reports, suspected diagnoses and confirmed findings are conflated.
- Unauthorised disclosure exposes sensitive personal or family information.
- Which of these failure modes and hazards hold for the sense of medical history this model covers, and on what evidence? provenance
Regional variation
Recalled without web access and unsourced; every item is a lead to verify.
- Documentation terminology, templates and expectations vary across health systems and clinical specialties.
- Privacy, access, retention and information-sharing requirements vary by jurisdiction.
- Patient identification and interoperability arrangements differ between countries and organisations.
- Which of these regional variation hold for the sense of medical history this model covers, and on what evidence? provenance
Neighbouring kinds and how to tell them apart
Recalled without web access and unsourced; every item is a lead to verify.
- Medical record - The medical record includes examination findings, test results, orders and other documentation; medical history is one component.
- History taking - History taking is the activity of eliciting information; medical history is the resulting account or its informational content.
- Physical examination - A physical examination supplies observed or elicited bodily findings; a medical history principally supplies reported and previously documented information.
- Problem list - A problem list summarises identified health problems; a medical history also records chronology, context and relevant experiences.
- History of medicine - History of medicine studies the development of medical knowledge and practice rather than an individual's health and care.
- Which of these neighbouring kinds and how to tell them apart hold for the sense of medical history this model covers, and on what evidence? provenance
What the second pass must settle
- Does the registry intend medical history to cover both the informational account and history-taking, or should the activity remain exclusively in a neighbouring model?
- Which existing Vercy models already own patient identity, medical records, medication exposure and clinical events, and where should this model link to them?
- Which terminology and exchange standards should guide condition status, reaction classification, missingness and approximate historical dates?
- What review criteria establish sufficient coverage and freshness for each intended clinical use?
- Which jurisdictional, institutional and patient-specific rules govern sensitive history segments, third-party information and correction rights?