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How to Modify Simple Medical History

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hey guys welcome back to the channel if youre new here my name is Aaron Im a junior doctor training in ophthalmology in London and graduates from Temple University two years ago and on the side about some medical education content onto YouTube Instagram and Twitter so go put me on there links to all the socials are in the video description so a couple of weeks ago I be do on the retrospective approach to preparing for medical school las diez and since then Ive had loads and loads of requests to make a similar video on history-taking okay so Im joking actually the only one person asked this video but hopefully a few of you find it useful in this video well look at the four parts that make up a good history well put this all into one neat structure that you can follow and then well look at how you can present your history findings in a clear and concise manner as usually where everything we types up below in the description and the pin comment so feel free to jump to any particul

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What are the 4 components of a patients 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.

How do I get a detailed medical history?

Following a Structure 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. Ask the patient about their family history.

What is included in 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.

How do you document medical history?

How To Properly Document Patient Medical History In A Chart Presenting complaint and history of presenting complaint, including tests, treatment and referrals. Past medical history diseases and illnesses treated in the past. Past surgical history operations undergone including complications and/or trauma.

What are the steps in the medical documentation?

The basics of clinical documentation Date, time and sign every entry. Write your name and role as a heading and the names and roles of all others present at the encounter. Make entries immediately or as soon as possible after care is given. Be legible. Be thorough, accurate, and objective. Maintain a professional tone.

How do you chart past medical history?

How To Properly Document Patient Medical History In A Chart Presenting complaint and history of presenting complaint, including tests, treatment and referrals. Past medical history diseases and illnesses treated in the past. Past surgical history operations undergone including complications and/or trauma.

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