Comprehensive Medical History Interview: Practical Guidance
Christopher R. Brigham
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Steven Feinberg
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Waqas A. Buttar
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Abstract

Independent medical evaluations (IMEs), impairment assessments, and providing clinical care mandate obtaining an appropriate history. The medical interview is a crucial component for obtaining an accurate and complete medical history for IMEs, which requires interpersonal and analytical skills. The interview is a purposeful conversation aimed at understanding the patient's experiences, with a focus on verbal and nonverbal cues, to help build a comprehensive understanding of the patient's injury and current problems within the context of their overall health. The extent of history that is documented depends on the purpose of the evaluation and the nature of the injury. The process involves documenting chief complaints, injury details, pre-existing conditions, clinical course, current symptoms, and functional and past medical history.

  • 1.

    Walker HK, Hall WD, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Butterworths; 1990.

  • 2.

    Rich EC, Crowson TW, Harris IB. The diagnostic value of the medical history: perceptions of internal medicine physicians. Arch Intern Med. 1987;147:19571960.

    • Search Google Scholar
    • Export Citation
  • 3.

    Brigham CR, Direnfeld LK, Feinberg S, et al. Independent medical evaluation best practices. AMA Guides Newsletter. September/October 2017;22(5):318. doi:10.1001/amaguidesnewsletters.2017.SepOct01.

    • Search Google Scholar
    • Export Citation
  • 4.

    Els C, Gelinas B, Carter RM, Kertay L. Best practices for the independent medical examination of mental and behavioral disorders. AMA Guides Newsletter. July/August 2022;27(4):1859. doi:10.1001/amaguidesnewsletters.2022.JulAug02.

    • Search Google Scholar
    • Export Citation
  • 5.

    Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Accessed November 29, 2023. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf.

    • Search Google Scholar
    • Export Citation
  • 6.

    Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Accessed November 29, 2023. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

    • Search Google Scholar
    • Export Citation
  • 7.

    Iglesias M. Comorbid conditions in workers' compensation. AMA Guides Newsletter. September/October 2019;24(5):813. doi:10.1001/amaguidesnewsletters.2019.SepOct02.

    • Search Google Scholar
    • Export Citation
  • 8.

    Centers for Medicare & Medicaid Services. Agency for Toxic Substances and Disease Registry. Exposure History Form. Accessed November 20, 2023. https://www.atsdr.cdc.gov/csem/exposure-history/docs/CSEMExposHist-26-29.pdf.

    • Search Google Scholar
    • Export Citation
  • 9.

    Engel GL. What if music students were taught to play their instruments as medical students are taught to interview? Pharos. 1982;45(4):1213.

    • Search Google Scholar
    • Export Citation
  • 10.

    Okland TS, Gonzalez JR, Ferber AT, Mann SE. Association between patient review of systems score and somatization. JAMA Otolaryngol Head Neck Surg. 2017;143(9):870875. doi:10.1001/jamaoto.2017.0671.

    • Search Google Scholar
    • Export Citation
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