Components Of Medical History Flashcards
1
Q
Personal data
A
- correct name, address, telephone number, date of birth, insurance information
- must review every visit
- initial physical, lab work, medication list
2
Q
Chief complaint
A
- reason for seeking medical attention in patient own words
- onset of symptoms
- description of pain or discomfort
- treatment patient tried at home
- patient opinion of problem
3
Q
Past medical history
A
-immunization, children illness, allergies, accidents, surgeries, past hospitalization and any major illnesses
4
Q
Family history
A
Immediate family members
- state of health, cause of death
- information of genetic or familial disease
5
Q
Social history
A
Information about employment, education, lifestyle choices, diet / exercise, use of alcohol, tobacco, drugs and sleep habits
6
Q
System of review
A
Area of present illness is discussed and charted
- head to toe systemic assessment
- look at all aspects by reviewing all body systems
- may discover valuable clues the patient did not think were relevant to current situation
- may uncover early sign of problems can be addressed before becoming problematic
