What should be documented regarding PMH medical and surgical history?

The documentation of past medical and surgical history is crucial for providing comprehensive patient care and understanding the patient's overall health status. Including surgical history only if it is contributory acknowledges that not all surgical procedures might have direct relevance to the current clinical situation or diagnosis. It highlights the need to focus on those surgical histories which have a potential impact on the patient's current health or treatment plan. This approach ensures that the healthcare provider has pertinent information that facilitates better decision-making while avoiding unnecessary details that may dilute relevant medical history.

In clinical practice, it's important to document surgeries that could influence treatment, such as previous operations that might affect anatomy, healing, or response to medications. This targeted approach maximizes the efficiency and relevance of the medical record, ultimately leading to more effective patient care.