這種醫生收集患者過去和當前相關醫療狀況的資訊,以做出明智臨床決策的做法稱為病史和身體檢查(History and Physical,簡稱為 H&P)。[1]臨床醫生(英语:clinician)在收集病史治療時,要熟練地提出適當和相關的問題,好讓他們對患者正經歷的狀況有深入的了解。關於病史的標準化格式會從主要關注點開始(患者為何會來診所或是醫院?),其次是當前的病史(症狀性質或是擔心處)、過去的病史、過去的手術史、家族病史、社會病史、藥物治療、過敏和系統審查(英语:review of systems)(對可能會影響身體其他部位的症狀進行簡要的全面檢查,以確保沒遺漏任何嚴重事項)。[2]詢問過所有的重要問題之後,通常會進行重點體檢(即只針對與主要擔心的相關事項)。經由H&P取得資訊後,安排化驗室和成像檢驗,並根據需要進行藥物或手術治療。
^ 3.03.13.2Quilliam, S. 'The Cringe Report': Why patients don't dare ask questions, and what we can do about that. Journal of Family Planning and Reproductive Health Care. 2011, 37 (2): 110–2. PMID 21454267. doi:10.1136/jfprhc.2011.0060.
^ 5.05.1Pappas, Y; Všetečková, J; Poduval, S; Tseng, PC; Car, J. Computer-Assisted versus Oral-and-Written History Taking for the Prevention and Management of Cardiovascular Disease: a Systematic Review of the Literature.. Acta Medica. 2017, 60 (3): 97–107. PMID 29439755. doi:10.14712/18059694.2018.1.
^Pappas, Yannis; Wei, Igor; Car, Josip; Majeed, Azeem; Sheikh, Aziz. Computer-assisted versus oral-and-written family history taking for identifying people with elevated risk of type 2 diabetes mellitus. Car, Josip (编). Cochrane Database of Systematic Reviews. 2011: CD008489. PMID 22161431. doi:10.1002/14651858.CD008489.pub2. hdl:10547/296945.|issue=被忽略 (帮助)
^Brandberg, H; Sundberg, CJ; Spaak, J; Koch, S; Zakim, D; Kahan, T. Use of Self-Reported Computerized Medical History Taking for Acute Chest Pain in the Emergency Department - the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS): Prospective Cohort Study.. Journal of Medical Internet Research. 27 April 2021, 23 (4): e25493. PMID 33904821. doi:10.2196/25493.