Bold look in the Patient Medical History

Aug 6th, 2022
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How to bold look in the Patient Medical History

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Dr. Rishi Desai here from Osmosis. and Im going to talk to you today about three tips to taking a really good patient history really important stuff. My advice to you again is, of course, you know how to get a patient history. the mechanics of it are pretty straightforward in the sense of you have a chief complaint, a main issue that they are therefore sometimes called presenting complaint. And then you have that HPI, the History of Present Illness. You have the past medical history, the medications and allergies, family history, social history, all that kind of stuff, review of systems thats the mechanics of it. But my tips on how to do a good job getting it. Thats what were here for. So lets start with my first tip, which is listen well and empathize. So keep in mind. The person is coming to you, They could go to a robot and then they can get all these questions answered. like, how long has the pain been there? where does it radiate to? All that stuff a robot can tell them or s

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A record of information about a persons health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests.
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patients medical history and care across time within one particular health care providers jurisdiction.
In general, a medical history includes an inquiry into the patients medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
a description of the patients condition and course of care since the history and physical examination was performed, and. a signature and date on any document with updated or revised information as an attestation that it is current.
The past medical history (PMH) in contrast records information about the patients medical, personal and family history that might be relevant to the presenting illness or to provide optimal clinical management.
The HPI is a chronological description of the development of the patients present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements: location; quality; severity; duration; timing; context; modifying factors; and associated signs and symptoms.
The medical history, case history, or anamnesis (from Greek: ἀά, an, open, and ή, mnesis, memory) of a patient is a set of information the physicians collect over medical interviews.
Several terms are used interchangeably to describe a patients medical chart, including medical record, health record, and patient chart. All refer to a private medical record that contains systematic documentation of an individual patients important clinical data and medical history over time.

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