What is included in a patients 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 information is included in a patients medical record?
Medical records are the document that explains all detail about the patients history, clinical findings, diagnostic test results, pre and postoperative care, patients progress and medication. If written correctly, notes will support the doctor about the correctness of treatment.
What does PMH mean in medical records?
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.
What is included in a medical history quizlet?
Past illness, treatments, operations, accidents, physical defects, allergies, childhood diseases, immunizations. Year or age event is recorded. Past operations - type of surgery, date or age. Medications past or present.
How do I fill out a health history?
Determine the following: Biographical data. Source of history. Reason for seeking care and history of present health concern. Chief complaint. Past health history. Allergies (reaction) Family history. Functional assessment (including activities of daily living) Developmental tasks. Cultural assessment.
What are the components of patient medical history?
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.
What should be included in a patients past medical history?
Please list any past medical history below with date of onset or diagnosis. Examples include asthma, diabetes, depression, anxiety, drug or alcohol dependency, high blood pressure, thyroid disease, autoimmune disease, chronic pain, gynecologic disorder. Have you ever had surgery?
What is considered personal health information in Canada?
Personal health information is information in any form that identifies you and that relates to your health and health care including, health history, health care programs and services, health care providers, substitute decision-makers, health card number and other personal identification numbers.