Failure to Take the Patient’s Medical History into Account

When caring for a patient, a doctor must consider the patient’s medical history in order to treat the patient safely and effectively. Especially with new patients, doctors must spend sufficient time with the patient to develop a full medical history. The medical history will contain some or all of the following information:

• Identifying information about the patient, such as name, age, height, and weight;
• The patient’s current main health problem (the problem that led the patient into the doctor’s office) and how long it has lasted;
• The history of the patient’s current main health problem;
• the patient’s past medical history, including:

o   major illnesses or injuries,
o   previous surgeries, and
o   current, ongoing illnesses;

• Review of the patient’s organ systems;
• Illnesses in the patient’s family, especially those related to the patient’s current main health problem;
• Illnesses the patient suffered as a child;
• The patient’s social history, including:

o   marital status,
o   number of children,
o   household and living arrangements,
o   occupation,
o   recreational drug use,
o   exposure to environmental causes of illness through recreational activities or pets, and
o   recent travel to foreign countries;

• The patient’s medication usage:

o   prescription drugs,
o   over-the-counter drugs, and
o   natural or complementary remedies;

• Allergies to food, medication, or other substances; and
• Sexual history.

From the above list of items, it is apparent that a doctor needs a lot of information about his or her patient to make sound medical judgments to treat the patient’s current illness or injury. Failing to consider the patient’s medical history could lead to severe harm to the patient.

For example, a patient might have an infection that requires antibiotic treatment. She might be allergic to penicillin or other drugs like it; however, if the doctor does not consider the patient’s history—or does not ask about it—he or she might prescribe a medicine that could cause the patient to have a severe allergic reaction.

As another example, consider a patient who has a history of bipolar disorder and goes to see his primary care doctor because he has been feeling depressed. If the primary care physician does not know about the patient’s bipolar illness, he might prescribe an antidepressant medicine for the patient that could trigger a serious manic episode that harms the patient.

It is very important for any health care provider to consider the patient’s medical history, and the failure to take the patient’s medical history into account may be a form of medical malpractice.

It is important to note that different types of doctors will require a different medical history.  For example, an ER doctor treating a potential stroke patient is concerned with when the stroke symptoms began.  By contrast a family practitioner treating a a viral infection, may be more concerned with allergic reactions.

Contact a Miami Medical Malpractice Lawyer Today

If you or a loved one was injured because a health care provider failed to consider your medical history properly, please obtain appropriate medical treatment immediately. Then please contact us for a consultation about your case. The consultation is free and confidential. You can call us at 305-372-0123 (local) or 866-769-0123 (toll-free) or contact us via our convenient online form to set up your consultation. For no charge, you can tell us about your injury and we will explain to you how the legal system may handle your case. We look forward to hearing from you.