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How to Type Simple Medical History

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Evan, a GP registrar, greets a patient and seeks to understand their issue. The patient reports experiencing diarrhea for the past two to three weeks, indicating they had no prior issues, typically having bowel movements every couple of days without problems. The diarrhea is described as frequent but otherwise normal in color and consistency. Evan inquires further about the symptoms, specifically asking if there is any blood in the stool. The patient seems surprised by the inquiry, suggesting that there may be more to discuss regarding their condition.

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What are the three common types of medical records?

There are three types of medical records commonly used by patients and doctors: Personal health record (PHR) Electronic medical record (EMR) Electronic health record (EHR)

What are 3 components to obtaining a good medical history?

Basics of history taking Establish a good physician-patient relationship. Precise documentation of symptoms. Develop a differential diagnosis.

What are the four purposes of medical records?

Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

How do I write my medical history?

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.

What are the 5 components of a medical record?

Here are the ten components of a medical record, along with their descriptions: Identification Information. Medical History. Medication Information. Family History. Treatment History. Medical Directives. Lab results. Consent Forms.

What are examples of medical history?

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 components create a patients history?

For example, a problem-focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), while a detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS) and pertinent past, family and/or social history (PFSH).

What are the 4 components of 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.

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