Work in detail in the Patient Medical History

Aug 6th, 2022
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How to work in detail in the Patient Medical History

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In this video, Karma Medic, a final year medical student at King's College London, discusses the importance of taking patient histories in clinical practice. He shares key insights gained during his medical education to help viewers improve their skills in this area. While emphasizing that he is not a doctor and the content is for educational purposes only, he presents a collection of useful techniques and information for those seeking structure in their approach to taking patient histories. The video aims to aid viewers who may need guidance in this essential aspect of healthcare.

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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.
Create a Checklist Greet patients and introduce yourself. Ask why the patient is being seen. Inquire about previous medical and surgical history. Ask about allergies and current medications. Request information about family medical history. Ask about social history, as well as smoking and drinking.
The summary must contain information for each injury, illness, or episode and any information included in the record relative to: chief complaint(s), findings from consultations and referrals, diagnosis (where determined), treatment plan and regimen including medications prescribed, progress of the treatment, prognosis
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.
Information Included in Medical Records Patient identification, contact information, and date of birth. Billing and health insurance details. List of current and chronic ailments and diagnoses. Current medications list with dosage.
A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.
The medical history, case history, or anamnesis (from Greek: ἀά, an, open, and ή, mnesis, memory) of a patient is a set of information the physicians collect over medical interviews.

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