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. 2017 Jan-Feb;109(3 Suppl 1):1–104. doi: 10.5935/abc.20170140

Recommendations for Collection of Medical History

Recommendation Class of recommendation Level of evidence
Obtain clinical history directly from the patient undergoing the procedure I C
Collect information in a succinct, objective, and focused manner, considering only the data relevant to the risk stratification algorithm used IIa B
In situations where direct data collection from the patient is impossible, obtain the data from relatives, acquaintances, or with the health professional who is accompanying the patient IIa C
Do not collect information from the patient's clinical history in the perioperative risk assessment III C