There are a number of crucial elements to be included in the medical narrative. The medical information in an individual’s history is important for the examiner to understand (Simpson, et. Al., 1991). Medical documentation is important in cases which are reported in places of employment or in school. These things can be used to claim accidents in cases which are applicable. However, certain criterion must be met.

There are generally six elements which need to be included in a medical history report. These are written down in narrative form and include: 1) dates of the examination and treatment, 2) History of past illnesses, 3) Physical findings – both positive and negative, 4) Any important or relevant test results, 5) Diagnosis; and 6) Course of treatment.

The medical history is basically all pertinent information regarding a patient’s health; this is information gained by a physician, or a compilation of findings gathered by a number of physicians (Stewart, 1995). The aim of this history is to provide the patient with the most suitable and efficient care for the patient’s utmost health.

The history includes the patient’s health status along with any complaints the patient may have regarding his or her health. These complaints are regarded as symptoms, and the proper diagnosis is given depending on the symptoms reported. This diagnosis is given as compared to clinical signs, which proper care is to be administered after (Stewart, 1995). Any other complaints in the past may be examined to determine any link to the patient’s current health status. Along with this, family history and any possible hereditary diseases are examined to see if the patient has any potential illnesses or diseases gained from genetics.