How to take a complete patient history
Other platforms explain it with text and video. In VMS you practice it on the patient.
The history gives most of the diagnosis before you touch the patient. Every program tests it: the AAMC lists it as the first Core EPA, and nursing and EMS exams expect the same order. Use the same structure every time so nothing is missed.
Step by step
Prepare and introduce yourself
Find a private, quiet place. Say your name and role, confirm the patient with two identifiers, explain that you will ask some questions and get their permission. Sit at eye level. [1]
Ask for the chief complaint
Start open: "What brings you in today?" Let the patient talk without interrupting for the first minute and write the complaint in their own words. [1]
Explore the symptom with OLDCARTS
Onset, Location, Duration, Character, Aggravating and alleviating factors, Radiation, Timing and Severity (0 to 10). Then ask what else came with it. [2]
Past medical and surgical history
Chronic illnesses, past hospital stays, operations, injuries, pregnancies and screening tests. Ask when each happened. [2]
Medications and allergies
Every prescription, over-the-counter drug, inhaler, supplement and herbal product, with dose and how the patient really takes it. For each allergy ask what happened. [2]
Family history
Health of parents, siblings and children: heart disease, stroke, diabetes, cancer and anything that runs in the family, with the age it started. [2]
Social history
Work, home and who lives there, tobacco, alcohol and drug use, diet, exercise, travel and, when it matters, sexual history. Ask without judging. [2]
Review of systems
Short head-to-toe questions to catch what the patient did not mention: fever, weight change, chest, breathing, bowel, urine, skin, mood and sleep. [1]
Summarize and close
Repeat the key points back, ask "Is there anything else?", ask what worries them and what they expect, then explain the next step and thank them. [1]
Common errors
- Closed questions too early: the patient never tells the full story.
- Interrupting in the first minute.
- Recording an intolerance (nausea) as an allergy.
- Skipping the patient's own concerns and expectations.
Practice it in VMS
In VMS you do this on the patient, not on paper: every step goes on the checklist with a score, and in Teach mode Blocky tells you what comes next.
VMS cases that train this skill
Sources
- AAMC Core Entrustable Professional Activities (Core EPAs)
- Open RN, Nursing Skills 2e (Chippewa Valley Technical College) (CC BY 4.0)
Steps adapted from Open RN, Nursing Skills 2e (Chippewa Valley Technical College), licensed under CC BY 4.0. Facts and steps also follow AAMC Core Entrustable Professional Activities (Core EPAs). VMS is not affiliated with these organizations. Updated: 2026-10-11.