KINNS MEDICAL HISTORY CHPT 21 Flashcards
What is a healthy state
More than absence of disease
What is a holistic perspective
Method of analyzing all factors that may contribute to the dev disease
First step in treating disease process
Step 1 in treating disease process is medical diagnosis
Differential dx
Considers which one of several dz may be producing sx
2nd step in treating disease
Provider considers all factors and comes up with working dx
Clinical Dx
Aka working dx
Aka Working dx
After hx, comprehensive physical exam, before lab tests, x rays or other dx testing is done
Final dx
Determined after all dx studies completed
When does pt care begin
When they contact the office
Collecting the history information
New pt completes health hx form (self history)
Taking hx
In private area, free of distractions
What is included in history information
Chief complaint (CC) purpose of the pts visit
Provider and Hx
May take hx on first visit
EHR
Incorp pts hx and physical exam directly in health record
Components of med history
Database; record of the pts demographic info
What is the Chief Complaing
Chief Complaint: purpose of visit
What is in the History of Present Illness
History of Present Illness (HPI)
What is in the Past History
Past History (PH) or Past Medical HIstory (PMH)
What is considered OTC
OTC Over the Counter Medications
What is in the Family History
Family HIstory (FH)- details about pt parents siblings
What is in Social History
Social History - info about lifestyle
What is in Systems Review
Systems Review (SR) or Review of Symptoms (ROS)
Meaningful Use
Providers required to collect info on allergies, pt hx, safe at home, alcohol use
Allergy documentation
Each office has policy on how
