INTRODUCTION:
A health history is a collection of information about a patient that can be used to better understand the chief complaint. Learn about information gathering tools, such as the patient interview, history of present illness and the review of systems. A health history is a collection of information from a patient that provides a picture of his or her current state of health. When a patient's health history is elicited properly, it supplies the medical professional with important facts that will assist in making a proper diagnosis and creating a beneficial treatment plan. In this lesson, we will learn about the elements needed to elicit a thorough patient health history.
Patient Interview
A patient interview, or patient consultation,
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Qualitative in-depth semistructured one-to-one interviews were conducted including 16 family physicians in Belgium. These interviews were recorded, transcribed, and analysed. Recurring themes were identified and compared with findings from the existing literature. All interviewed family physicians considered the family history as an important part of the medical records. Half of the surveyed physicians confirmed knowing the family history of at least 50% of their patients. The data on family history were mainly collected during the first consultations with the patient. The majority of physicians did not use a standardised questionnaire or form to collect and to record the family history. To estimate the impact of a family history, physicians seldom use official guidance or resources. Physicians perceived a lack of time and unreliable information provided by their patients as obstacles to collect and interpret the family history. Solutions that foster the use of family history data were identified at the level of the physician and also included the development of specific instruments integrated within the electronic medical
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
According to HIMSS The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. It includes information from patient demographics, medications, to the laboratory reports. Introduction of Electronic Medical Records in healthcare organizations was to improve the quality care and to lessen the cost by standardizing the means of communication and reducing the errors. However, it raises the “eyebrows” of many when it comes to patient confidentiality and privacy among healthcare organization.
LG stated that her family stays well educated regarding their health and family history and if they have any questions about the genetic problems in the family, they will typically research the internet and follow up with their general practitioner. LG, her siblings, and their mother are in good health and are not dealing with major medical matters at this time. Interventions for this family should be tailored to help them keep up on current information about heart disease, diabetes, and cancer, which are the main medical issues in their family medical history, and having a plan that ensures they continue getting regular health checkups. In conclusion, it is important for nurses to have proper training and information in the area of genetics and genomics so that it can be used in daily clinical practice (Thompson & Brooks, 2011). Using this information with clients and conducting a detailed genetic nursing assessment is a valuable component of being an effective health care provider and can help clients recognize, prevent, and/or treat diseases that are unique to their particular family.
Jethani,J. (2004). Medical records – its importance and the relevant law. Vision 2020, IV(1), Retrieved from http://laico.org/v2020resource/files/medical_records_Jan>mar04.pdf
A genetic family history assessment contains information about family structure and relationships. A typical nurse will use a three-generation family pedigree to gather the information. By doing so, nurses can be aware of which family members are at risk for disorders from a genetic component. Therefore, they can be provided with lifestyle advice, recommendations, and referrals to appropriate specialists (Kaakinen, Coehlo, Steele, Tabacco & Hanson, 2015). A genetic family history assessment will be provided about my family.
Medical patient history inlcude families history and the status of the family members death if known. It tells relationships of the patient, his or her career and schooling this helps the physician to know and explain behavior of a patient in relation to illness or loss. It contains different habbits such as smoking use , alcohol , diet and exercise. History of vaccination is included and blood test prooving immunity. If a patient is hospitalized there are daily updates that are entered in the medical record; it documents clinical changes and new information.
Doctors, hospitals and other care providers dispute that they should have access to the medical records and other health information of any patient citing that they need this information to provide the best possible treatment for proper planning. Insurers on the other hand claim they must have personal health information in order to properly process claims and pay for the care. They also insist that this will provide protection against fraud. Government authorities make the same arguments saying that in providing taxpayer-funded coverage to its citizens, it has the right to know what it is paying for and to protect against fraud and abuse. Researchers both medical and none nonmedical have the same argument saying that they need access to these information so as to improve the quality of care, conduct studies that will make healthcare more effective and produce new products and therapies (Easthope 2005).
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).
As a result, I always felt that I am actively participating in patients’ care. She allowed me to perform patient examinations most of the time and encouraged me to build up a good rapport with the patients. I think my past experience and medical knowledge was helped me lot during the history taking because I was able to go through history taking in a systematic manner and at the same time I could think of possible differential diagnosis. Furthermore, working in a medical clinic as a physician assistant also helped me a lot because one of the responsibilities delegated to me is taking patients history, however, this time it was different that I had to work out and actively think about a possible cause for patient concerns. The weakness I observe during history taking was sometimes I am little quick that might hurt the doctor-patient relationship, So, I am planning to improve my listening skill with less interruption to patients, I believe that might help the patient to express their concerns freely. Also, I am determined to listen to patients concerns in a non- judgemental manner to get the unbiased clinical
Throughout my life I have heard a wide range of stories from my parents. When putting this assignment together I have put these stories into account. Randall Bass, educator of English at Georgetown University, concurs that stories shape individuals ' personalities. Bass expresses that, "People infer their feeling of personality from their way of life, and societies are frameworks of conviction that decide how individuals experience their lives" (Bass 1). Social stories about family history, religion, nationality, and legacy impact individuals ' conduct and convictions. Personalities of diverse individuals originate from their societies. Narrating starts at home. Stories associate individuals to their frameworks of convictions. They shape individuals ' lives by giving them a model of how to live. Individuals get their most punctual learning from distinctive stories. (Bass)
Introduction and Importance A comprehensive history and physical (H&P) is a critical first step in the assessment of any patient. They often provide much more information than most broad examination and testing approaches do since the information is coming directly from the patient. Thorough H&P’s can help providers identify possible disease and illness helping aide in the diagnostic process and our frequently used as the foundation of medical management throughout an entire course of treatment with a provider. Identification
The actual first stage of the family life cycle is the family of origin experiences. During this phase the main task are building of a solid foundation, and maintaining relationships with parents, siblings, and peers. The family of origin is basically the family you grew up in, which is the center of what shapes who we are. A healthy family of origin exhibits a strong foundation that will be the center piece of that family unit. If effective the family will have a strong sense of togetherness, communication, separateness, and connectedness. This all helps the family to establish healthy boundaries between parents and their children, as well as resolve conflicts in a healthier and productive way. It is stated that when parents exhibit emotions like warmth and caring connections, it tends to promote individuality and
For example, clinician need to know certain dialek such as dialek Kelantan, so that the history taking session can run smoothly. Besides that, clinician also need to aware the use of medical terminology to the client. This is because they might not used to the terminology stated in the history taking form that require more details explanation from the clinician. For example, tinnitus is the perception of ringing or buzzing sound in the ear. Some clients may not familiar with this medical terminology if the clinician ask about tinnitus but understand it is a sound in the
Family history is very important to an individual. By knowing where you come from, you can have a better perspective of your life. Having a clear understanding of your family background allows you to better appreciate the things that you would normally take for granted. The house, the car, and the average clothing may look better when one sees the sacrifices their family has made. They will see that their family has worked very hard just so their family can experience the better things in life. A persons roots and origin is one of the most important things to explore. It alone can bring you closer to self-discovery.
My family and family history starts like most people’s. Two people fell in love, they had kids, their kids had kids and so on and so forth. But where we come from and who we are, is a completely different story. From our European roots, to the mixing of our blood once my family migrated to America, my family is quite complex but one that I am proud of and love greatly.