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