Obtain Medical History

Records should only show information that is essential to the service but there may be conflicts or dilemmas when a practitioner is asked to share information or the information might identify the person, or the information is confidential. The practitioner is unsure about the need to share the information, how much to share and when and how it can be shared.

Healthcare organizations have been tasked to explicitly define organizational requirements for what their facility maintains as a legal health record and maintains as a designated record set. The requirement that healthcare facilities maintain a designated record set, in addition to a legal health record, is a HIPAA privacy rule (AHIMA, 2011). While all healthcare organizations will uniquely define both record sets, in order to be in compliance with HIPAA their definitions must contain common principles (AHIMA, 2011).

Confidentiality, by not passing on information to anyone who isn’t involved in the individuals care, you must make sure you have the individuals consent. Protecting personal daily records, making sure that you keep them in a

This information is important when counseling individuals so that we don’t violate the patient’s privacy. Patients may disclose protected health information such as medical issues and medications during interviews or while filling out paperwork. Knowing that sharing this information is a HIPAA violation and has legal ramifications can save us from a lot of unwanted trouble. Also, knowing this will allow us to take extra care not to leave documents such as files or paperwork laying around that contains patient information. It allows us to know not to discuss with others, what a patient discusses with us. This information informs us of who we are allowed to share this information with. Sometimes it might be necessary to share information with a patient’s doctor in order to coordinate treatment or other services. In addition, it might also be necessary to speak to the patient’s provider about any food / medication interactions or possible food intolerance /allergies. It is also important to know for billing

A patient’s past health history may provide insight into causes of current symptoms. It also cues the nurse to certain risk factors for disease. A past health history includes childhood and adult illnesses, chronic health problems and treatment, and previous surgeries or hospitalizations (Lippincott et al.,2014).

Investigate and clarify how the patient meets criteria for the disorder(s) as per the patient 's side effects and the criteria sketched out in the symptomatic manual.

In the case of a patient being a new patient the first step is to make sure that the medical

Normal vision, ears are normal with no wax deposition. Pinna normal in appearance and normal hearing ability.

Medical background checks should be more mandatory if the person has a job or is purchasing a firearm also business need to address a lack of security in the general public places. In this case, James Holmes was arrested on July 20, 2012 for killing 12 people and wounding 58 more in a movie theater in Aurora, Colorado. The jury could not reach a unanimous decision on the death penalty so he will have another trial to decide his fate. On Wednesday Aug. 26, 2015 the judge has officially sentenced the murderer a life in prison. Furthermore, many people worry about the medical background checks reducing their pay checks weekly. Others are worried about why he wanted to kill them? Some asked why the shooter choose that particular theater. Shouldn’t

Moreover, diseases that require particular attention includes: heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and mental health disorders.

Thinking back to when I have done a health history I have luckily had good experiences. As a nurse I do not have much to compare to but I have had a dew admissions where I have obtained a health history. For one I can remember the patient was not verbal. He was in his 60’s and had multiple CVA’s. His 87 mother took care of him, along with his medications, doctors’ office and any car he needed. She had great family support with her other children so this made it a lot easier for her. At first when I received report from the ED that the patients mother would be providing the health history and medication history I was worried but I was wrong. The patient’s mother knew, off the top of her head, exactly what medication her son was on. To

Five key pieces of information most important for patients to know that under the following:

Patients should have access to their health record as it allows for a comprehensive understanding of their illness and health. Patients can have a sense of empowerment by participating in an active role in the decisions that both healthcare providers and patients to improve his or her health. By having access to health record, patients can advocate for their health and illness. Furthermore, patients who have access to their health record can improve the communication channel between physicians and patients such that patients are aware of why physicians are prescribing certain medications, and they gain a better understanding of their illness. For example, last clinical at Argyll Lodge (mental health facility), I had the privilege of working with a client diagnosed with type 2 diabetes mellitus. The client had no insight on why she was taking metformin and gliclazide medications. I worked closely with the client by teaching her what type 2 diabetes mellitus is, and showed her previous medical records (MARS) and lab results where she had high level of A1C, high blood concentration of cholesterol, triglycerides, and LDL. No charting was shown. I explained to the client the importance of maintaining an adequate level

Understanding a patient’s social history is vitally important in treating a patient holistically. The social context that the patient is exposed to in most cases causes the illness or aliment to arises. For instances understanding that a patient lives in a high stress environment with a high density of fast food restaurant can predispose the patient to hypertension. With this in mind the doctor can suggest various treatments and proceed to suggest diet advice that is tailor to the patient’s circumstances. HEADDSSS provides an excellent framework to understand the social context and history in which a patient lives in. In addition, by suddenly asking these questions and displaying a genuine interest it can allow the patient to open up to the

When working with other clients, individuals, or employees it is important to keep all information confidential. Confidentiality is extremely important, because violation is breaking HIPPA laws and the code of conduct. Confidentiality protects a client’s rights, where all information that is given is kept private. “Privacy refers to the person’s right to keep specific information private which includes the facility’s