LESSON#2 Flashcards
(17 cards)
is a structured framework for organizing patient information in written electronic and verbal form to communicate effectively with other healthcare providers
HEALTH HISTORY FORMAT
A conversation with a purpose within three folds using health history format
HEALTH HISTORY INTERVIEW
Patients information is confused organized into three categories
PAST
PRESENT
FAMILY HISTORY
Set the stage for a smooth interview
PRE-INTERVIEW phase
Is a continual part of professional development in clinical work
SELF REFLECTION
Put the patient at ease and establish trust
Establish rapport
INTRODUCTION phase
Obtain patient information
WORKING phase
Summarize important points
Discuss plan of care
TERMINATION phase
Are information from the clients point of view (symptoms) including feelings perceptions and concerns obtained through interviews
SUBJECTIVE DATA
Are observable and measurable data (signs) obtained through observation physical examination and laboratory and diagnostic testing
OBJECTIVE DATA
This section of the history is a complete clear and chronologic account of the problems prompting the patient to seek care. the native should include the onset of the problem the setting in which it has developed its manifestations and any treatments
HISTORY OF PRESENT ILLNESS (HPI)
Ask whether the patient has received vaccine for tetanus pertussis diptheria polio measles mumps influenza etc
Include the datas of original and booster________
IMMUNIZATIONS
Such as tuberculin test, cholesterol tests etc..
Maybe ask about during and documented in the review of systems
SCREENING TESTS
Outline or diagram on a genogram the h and health or age and cause of death of each immediate relatives including parents grandparents siblings children and grandchildren
FAMILY HISTORY
Understanding and using _________ are often challenging for beginning students.
Think about asking a series of questions going from head to toe.
REVIEW OF SYSTEMS
Section provides a guide for gathering personal or social history from the patient and daily living routines that may influence health and illness
HEALTH PATTERNS
Cultural constructs of mental and physical illness vary widely causing mark difference in acceptance and attitudes
THE MENTAL HEALTH HISTORY
