Cut line in the Professional Medical History effortlessly

Aug 6th, 2022
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How to Cut line in the Professional Medical History

4.6 out of 5
32 votes

so we talked about the chief complaint and the HPI and I want to just share with you how I look at the past medical history a little bit different than youve probably been taught in medical school the past medical history is predictive of the president and also of the future so past is prologue you need to know what the past is before you can determine what the persons present is and so for example if someone has a history of lung cancer wed like to know how high of a chance is this lung cancer to be causing whatever theyre here to see me and neuron fourth and so the in order to do that I need to have the stage of the tumor which means I need to know how extend how extensive is the cancer it can either be confined to the lung it can be outside of the lung it can be any widespread metastasis so in a patient who has stage 1 lung carcinoma thats a totally different risk than someone who has stage 4 lung cancer for whatever their complaint is and wed like to know what treatment the

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Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider. The general duties of a scribe may vary and can include: Assisting the provider in navigating the EHR.
No. Scribes do not touch patients, handle body fluids, or provide medical advice or interpretation.
Unprofessional or personal comments about the patient, or. Derogatory comments about colleagues or their treatment of the patient.
A scribe does not collect the patients information beyond vitals, nor do they present this data to the physician. A Scribe cannot perform medical procedures or screenings (such as for depression) because they have no medical training.
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.
Despite these advantages, practices should consider the following potential drawbacks of working with scribes: Very little training, regulation or oversight. Scribes cant do everything. Possibility of stifling EHR advances.
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. It may also include information about medicines taken and health habits, such as diet and exercise.
Medical Scribe responsibilities include: Preparing and assembling medical record documentation/charts for the physician. Updating patient history, physical exam and other pertinent health information in the patient. Organizing and sending all documentation to physician for review.

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