The PMH (Past Medical History) section on the Patient tab captures everything about the patient that predates this call — history, allergies, directives, pregnancy, and substance use.

The PMH section on the Patient tab with advance directives, barriers to care, medical and surgical history, allergies, pregnancy, last oral intake, and substance use fields.

Advance directives

  • Advance Directives — multi-select. Mark every directive the patient has (DNR, POLST, MOLST, living will, healthcare proxy, organ donor).
  • Emergency Information Form — whether an EIF (pediatric or special-needs emergency form) is available.

If you have a DNR or POLST in your hands, take a photo of it and attach it to the Documents section.

Barriers to care

  • Barriers to Patient Care — multi-select. Language, hearing, vision, cognitive, developmental, mental, or physical barriers that affected the call.

Medical history

  • Medical / Surgical History — multi-select with ICD-10 lookup. Type a condition (diabetes, hypertension, CHF, etc.) and pick from the matches. Add as many as apply.
  • Medical History Obtained From — multi-select. Who gave you the history (patient, family, medical records, bystander, EMD).

Allergies

  • Medication Allergies — multi-select with RxNorm lookup. Type the medication name.
  • Environmental / Food Allergies — multi-select with SNOMED lookup. Peanuts, shellfish, latex, bee stings, etc.

Pregnancy, intake, and substances

  • Pregnancy — only shown when Sex is Female. Current pregnancy status.
  • Last Oral Intake — date and time. Useful for potential surgery cases and stroke / cardiac workups.
  • Alcohol / Drug Use Indicators — multi-select. Observed or reported substance use.

An example

You respond to a 78-year-old with shortness of breath. The patient tells you he has CHF, COPD, and hypertension. He has a penicillin allergy that gives him a rash. His daughter is on scene with a POLST that says comfort measures only. In PMH: Medical / Surgical History CHF, COPD, Hypertension. Medication Allergies Penicillin. Advance Directives POLST. Take a photo of the POLST and attach it to the Documents section.

NEMSIS required: Medical history and allergy fields are NEMSIS-required when the patient was assessed. If the patient cannot tell you and no family is available, use the NV button to record Not Recorded or Not Applicable rather than leaving the fields blank.