Health History Assessment

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

A family health assessment is a process by which a nurse evaluates and describes the health status of a given family. It is a framework that helps to identify areas of potential risk for illness, opportunities for health education and actions needed to address these (World Health Organization, 2001). Specifics covered in a nurse led family assessment will include family history, perceptions about health, reports, health records, and any clinic test results. The nurse conducts an interview, compiles data and performs an appropriate

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

Family health assessment is an integral part of the formula used in creating a customized plan of care for the families’ health care. Family health assessment is also a tool that can be used to identify and evaluate the family’s health concerns, their life style and also helping families make good decisions regarding their family’s health. Family’s perception towards health and health promotion could be very different and unique, which makes the Family health assessment even more challenging for the nurses and health care professionals. Nurse’s have a moral obligation towards the society to help them promote their families health. The

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Every patient that comes in seeking medical attention, has had a health history assessment conducted on them. Such an assessment provides health care workers such nurses, with vital information about the patient’s overall well-being. It can also be viewed as a guide in directing the nurse, in provided the most beneficial and utmost plan of care. The purpose of this paper is to exemplify a conducted health history assessment on a patient represented by the initials L.H.; Which focuses on subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings.

Whitlatch (2013) defines a family assessment as a process of gathering, systematizing and analyzing information to help the family take preventative or problem-solving measures. A family assessment presents an unbiased view of overall understanding of a family- not merely problems, but also its needs, strengths, values and goals. As these dynamic features keep changing over time, a family assessment is an ongoing exercise (Whitlatch, 2013). When an assessment is undertaken with a solution-focused approach to identify family 's strengths and potential to prevent or solve health issues, it is termed as a family strengths assessment. It helps understand health issues and the needs from the family’s perspective and plan a healthcare accordingly utilizing the family 's inherent strengths to yield a positive health outcome. (Peterson, Blackburn, Bazemore, OʼNeill, & Phillips, 2014)

They can not give medicines or surgery before they ask questions to patients about their medical history and qualitative and quantitative data because if the they give them wrong medicine then it might bring another side effect or it might take away the patients life. As according to the Development and important of health needs assessment is the systematic approach to ensuring that the health service uses it resources to improve the health of the population in the most efficient way. It involves epidemiological, qualitative, and qualitative, and comparative methods to describe health problems in a population. Qualitative data use by health department is to measure the amount or rate of the born, death, and etc. The qualitative is like doctor observe from the patients’ symptoms and determine what kind of problems they have. Thus, needs assessment is very important in health care system to determine priorities for improving health for people in community. Also, it is the only way to find out the evidence and planning health

It begins with assessment and including an evaluation of the perceptions by the person, the person 's family, and the nurse. This is where subjective and objective data is gathered and recorded. It is a holistic assessment which covers the patient’s physiological, psychological, sociological, cultural and spiritual status. Information is collected by the nurse interviewing the patient, giving a physical exam, getting the patients’ health history and family history. For example, if a patient came into the hospital after a fall at home the nurse would start by gathering information that lead up to this point. The nurse would find out what the patients complications are from the falls, the frequency of falls, cause of the fall, or are there underlying causes. They would get medical history, family history, mental status, environment, and medications. The nurse would do a head to toe assessment and from there would begin diagnosing the patient appropriately.

An appointment was made with this family prior to the visit scheduled and the purpose of the visit and the role of this student nurse in health promotion and disease prevention through stages of family development was explained as an introduction part. The entire family was invited to participate in the discussion. The family was made aware of HIPPA violation and the responsibility of the nurse to keep all information shared confidential. Mathew’s family consists of him, his wife

In this case study, there is a patient named Mr. Wilson who is a 70 years old man. He stated that he had difficulty in breathing and caught a ‘flu’ a week ago. Currently, he has been observed pitting oedema on his lower legs. In addition, the patient had history of heart attacks, which has been diagnosed with congestive heart failure. The case study will provide a complete care plan for the patient. Its aim is to provide a better quality of care for the patient as well as promoting holistic treatment of the patient. The report will firstly assess the patient’s condition by two nursing assessment tools while offering rationale for choosing these assessment tools. The client’s health problems will then be identified and

Increased public demand to access health information and growth of consumerism in health care industry are two important reasons form increasing attention to Personal Health Records (PHRs) in the recent years. Surveys show that a considerable number of people want to have access to their health information. In one survey, 60 percent of respondents wanted physicians to provide online access to medical records and test results, and online appointment scheduling; 1 in 4 said they would pay more for the service.

Assessment is the accurate collection of comprehensive data pertinent to the patient’s health or the situation (“American Nurses Association,” 2010). Assessment is the first step in the nursing process and the most important. Assessment is the accurate collection of the patient’s health date

Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that

health pattern as well as the family based nursing diagnosis and also discuss different health