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Aug 6th, 2022
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How to Link tag in the Personal Medical History

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my name is Kevin Kennedy education training officer for Simons Service NHS Trust today Im going to be talking you through the history taking model and Im going to be assisted by my colleague Erin whos going to be a simulated patient with today the his taking module looks at nine subsections and were going to be talking through each of those as we go through the process of this history take if youre taking starts off with your normal smart approach good general observations and your introduction to the patient more than sir my name is Carolyn from the Alex service whats your name sorry I have a nice to meet you and I believe you called trouble nine today is that correct yeah yeah okay what seems to be the problem Ive just got this chest pains quite sharp okay all right at this moment Tommy you okay Rogers privacy in text yeah please check see no Im absolutely fine thank you okay so what I want to do then is if I can just got a little bit more history about whats been happenin

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It includes informationally typically found in paper charts as well as vital signs, diagnoses, medical history, immunization dates, progress notes, lab data, imaging reports, and allergies. Other information such as demographics and insurance information may also be contained within these records.
A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams, tests, and screenings. It may also include information about medicines taken and health habits, such as diet and exercise.
At its simplest, your record should include: Your name, birth date and blood type. Information about your allergies, including drug and food allergies; details about chronic conditions you have. A list of all the medications you use, the dosages and how long youve been taking them. The dates of your doctors visits.
At its simplest, your record should include: Your name, birth date and blood type. Information about your allergies, including drug and food allergies; details about chronic conditions you have. A list of all the medications you use, the dosages and how long youve been taking them. The dates of your doctors visits.
The ten main components of a Medical Record are: Identification Information. Medical History. Medication Information. Family History. Treatment History. Medical Directives. Diagnostic Results. Consent Forms.
Basics of history taking Establish a good physician-patient relationship. Precise documentation of symptoms. Develop a differential diagnosis.
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 medical record is a systematic documentation of a patients medical history and care. It usually contains the patients health information (PHI) which includes identification information, health history, medical examination findings and billing information.

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