Link light in the Past Medical History Form

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How to Link light in the Past Medical History Form

4.6 out of 5

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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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What does pertinent history mean?

adjective. pertaining or relating directly and docHubly to the matter at hand; relevant: pertinent details.

What is included in a patients past medical history?

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.

What are examples of past medical history?

Past medical history Childhood illnesses. Major adult illnesses. Past surgical history, including type, date, and location of past surgical procedures. Medications. Prescription drugs. Allergies. Prior injuries (e.g., motor vehicle accidents, falls) Prior hospitalizations and/or transfusions. Immunizations.

What does past medical history pertinent negatives mean?

Pertinent Negatives (PN) are used when the clinician documents why they DID NOT perform a procedure. Example: If Aspirin is part of the agency protocol for Chest Pain but was not administered, the reason should be documented. This is done using PN values.

What is the acronym for past in medical terms?

In a medical encounter, a past medical history (abbreviated PMH), is the total sum of a patients health status prior to the presenting problem.

What does pertinent past medical history mean?

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the History of Present Illness (HPI). At least one specific item from any of the three history areas must be. documented for a pertinent PFSH.

How do you ask a patient about their past medical history?

Generally speaking, most patient history conversations are as follows: Greet the patient by name and introduce yourself. Ask, What brings you in today? and get information about the presenting complaint. Collect past medical and surgical history, including any allergies and any medications theyre currently taking.

What are pertinent medical records?

At a minimum, pertinent records include problems, medications, and allergies. Laboratory results obtained as part of clinical research but pertinent to medical care would be included in the LMR unless otherwise prohibited.

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