Strike point in the Child Medical History

Aug 6th, 2022
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How to strike point in the Child Medical History

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The history of present illness is crucial in history taking and consists of three main components known as the "three Cs." First, determine the system involved, such as cardiac, respiratory, gastrointestinal, central nervous system, renal, endocrine, or hematological. This identifies "what is the case." Second, establish the cause of the symptoms, identifying the disease affecting the involved system. Lastly, assess any complications arising from the disease. For example, if a patient presents with breathlessness, these three components help in diagnosing and understanding the patient's condition effectively.

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Use clear, concise language and avoid unnecessary details. Ensure that all relevant information is included in the note, including the patients medical history, physical examination findings, assessment, and plan of care. Use objective language when documenting the physical examination findings and assessment.
Natal: Duration of pregnancy, birth weight, kind and duration of labor, type of delivery, presentation, sedation and anesthesia (if known), state of infant at birth, resuscitation required, onset of respiration, first cry.
The combination of abnormal arms in the triangle determines the childs category of illness and helps to identify the immediate intervention. Appearance is illustrated by the TICLS mnemonic (Table 1): Tone, Interactiveness, Consolability, Look or Gaze, and Speech or Cry.
Initial Assessment The triangle has 3 components: Appearance of mental status and muscle tone. Work of breathing including rate and effort. Circulation; assessing skin color/condition.
7 Essentials to Writing Effective Pediatric OT SOAP Notes Use a consistent structure and flow. Create a unique note for every appointment. Establish a reasonable number of goals. Complete notes in a timely manner. Make sure your notes are legible. Include all the details of the session. Dont include unnecessary information.
15 Actionable Tips to Write Professional Progress Notes Use clear and concise language. Follow a structured format. Include objective observations. Document treatment methods and modalities. Assess safety and risk. Focus on critical information. Review and reference previous sessions.
Past history Start with any conditions that still affect the patient. Previous hospital admissions with dates and diagnoses. List of prior procedures and dates. Any prior trauma: fractures, lacerations. For more information, see Past medical history. in medical history.

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