Revise quote in the Professional Medical History

Aug 6th, 2022
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How to revise quote in the Professional Medical History

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Martin B. Brodsky: Hi, Im Martin Brodsky. Im going to speak to you today about deriving clinical meaning from medical chart review. My financial disclosures are that Im employed by Johns Hopkins University. My research is funded by NIH and very specifically right now NIDCD. I am receiving financial compensation from ASHA for this presentation. And I dont have any nonfinancial disclosures. The goals for this session are: Explain the goals for medical chart review; reason which areas of the medical chart are needed to inform speech language pathology diagnosis and treatment goals; and reflect on and employ at least two pragmatic and time saving tips to assist with effective and efficient navigation of the medical setting. So why complete a medical chart review? Whats the point to it all? ing to ASHA 2004 in their practice patterns document they said: Statements that define generally applicable characteristics of activities directed toward individual patients or clients and that a

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The purpose of obtaining a health history is to gather data from the patient and/or the patients family, so the healthcare team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions.
The following is a list of items you should not include in the medical entry: Financial or health insurance information, Subjective opinions, Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
The information can be used to help: understand more about disease risks and causes. improve diagnosis. develop new treatments and prevent disease.
Understanding a patients history helps identify disease risk factors. Doctors might recommend regular screening tests, lifestyle changes, or preventive medications for someone with a family history of heart disease. Moreover, an accurate medical history can identify patterns even before symptoms appear.
A family health history can identify people with a higher-than-usual chance of having common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and type 2 diabetes. These complex disorders are influenced by a combination of genetic factors, environmental conditions, and lifestyle choices.
History of Present Illness o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o What makes it worse Any other symptoms that you have?
It should include some or all of the following elements: Location: What is the location of the pain? Quality: Include a description of the quality of the symptom (i.e. sharp pain) Severity: Degree of pain for example can be described on a scale of 1 - 10. Duration: How long have you had the pain.
The purpose of obtaining a health history is to gather subjective data from the patient and/or their care partners to collaboratively create a nursing care plan that will promote health and maximize functioning.

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