HEALTH HISTORY
Date: 05/09/2015
Initials: J. B
Age: 50
Date of birth: 04/03/1946
Birthplace: Kumasi, Ghana
Gender: Male
Marital status: Married
Race: Black American
Religion: Christian
Occupation: Clerk at USPS
Health insurance: Employer provides medical, dental, and vision
Source: Primary – patient provided all information
Reliability: Reliable, alert, oriented, able to recall accurate information.
PRESENT HEALTH HISTORY/ILLNESS
Reason for seeking care Patient states his body, hands and head shakes when walking or sitting
Health beliefs and practices Patient believes health is definitely important and visits his doctor when problems persist or are troubling.
Health patterns Patient attends physical exams at least twice every year.
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He is a father of three boys.
Ethnicity and culture No specific beliefs, patient states “I consider myself to be an African and adhere to the Ghanaian culture”
Family Close relationship with all family members both in the united states and Ghana. Patient also tries to keep in touch with family often as possible.
Spirituality Roman, Catholic
Self-concept Views himself as an independent, reliable and loyal man
REVIEW OF SYSTEMS
Skin, hair, nails Skin: oily on face around nose and chin, no other abnormalities.
Nails: patient have very hard fingernails, no color
When patients go to a doctor’s office, they need to know that the PA/NP that is treating them is highly qualified. They should feel safe and know that they are in safe capable hands. A patient should never feel like they are not getting the proper care. Patients need to know that they are being
The client weight is 70 kg and has maintain same weight for past 10 years and is 5 years
2. What additional questions should you ask regarding this patient’s chief reason for seeking care?
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).
Interacting with these patient taught me about the challenges they face establishing reliable care. They are often assigned to one of the few clinics in town who will accept such challenging patients for such low reimbursement. Getting to the clinic may require arranging transportation that can deliver the patient to and from an office visit or referral. Often the clinics these patients are assigned to are overcrowded and may not be able to see the patient for weeks or even
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.
Family members, at times, can be of great assistance, but then HIPPA comes into play. The patient may not want a particular family member to know about their health problems. The language barrier does inhibit sufficient care, and this should be addressed with the utmost of care and consideration for both the medical staff and patient.
A.P.’s strength would be her willingness to learn and be educated about health safety and issues. She is receptive to information about ways to lose weight and how to quit smoking. She is interested in discovering how her health history can show possible future health risks. Her weakness is a lack of knowledge concerning current health problems. She neglects to visit the doctor regularly for medication evaluation or preventative care.
Patients seek medical attention for preventative measures, as well as, diagnostic measures. Patients must have a trusting rapport with their collaborative medical team, as the nurses and the doctors are the people who they trust their lives with. Patients do not always present to hospitals, urgent cares, walk-in clinics, or even doctor’s offices only when they are sick; patients visit to ensure their good health will continue, treatment regimens are of benefit, changes that may be needed in regimen. When someone thinks of a patient they may think of some of these characteristics: illness, disease, hospital, medications, health, and prevention.
In both cases though, it was important that doctors were attentive and built up good relationships to instil trust. I took the opportunity to speak with the patients themselves about what they want from their health
Family is playing an important part in helping to ensure that patients are fit and following the advice of health care professionals. This is because the family is a foundation of support for everyone. At the same time, members can learn about what is impacting their loved one and what kind of procedures need to be followed. When this happens, there will be higher amounts of compliance as they will ensure that the patient continues to stick with their treatment protocol. (Saleeba, 2009)
The major purpose of taking patients’ health history is to set the preliminary for the practitioner to enabling them to explicitly diagnose the patient’s health problem and also give their consideration to the patient’s social, psychological, and behavioral background (Celia, 2013). The process of taking a comprehensive health history is considered as the most significant aspect that allows patients to provide their concern of their present illness including symptoms, their current perceives and management of illness to the health practitioners, and the procedure is progressively being undertaken by nurses (Lloyd & Craig, 2007). According to Jarvis (2012) taking the interview for history healthcare assessment is the very first important part
Patient does not have a present illness. He is only seeking care for the purpose of providing a health
Visiting the doctor has never been viewed as an enjoyable experience for clients. It is likely considered to be a necessary evil, something that must be done but is not pleasantly anticipated. Making the encounter between health care professional and client both helpful and therapeutic can be a challenge. This is especially true for those whose financial situation is precarious, meaning, one pay check away from being homeless. So not only does the client arrive for their scheduled appointment with the normal anxiety visiting the doctor brings; added to this is fear of a serious diagnosis, and the stress of finding the funds to pay for medical services, medications, and any follow-up visits that may be required. The extra expenses will
Health care in Canada is delivered through a publicly funded health care system called Medicare, which is a universal coverage, single payer plan for all Canadians and legal residents. This health insurance pays up to 70% of all medicals costs excluding dental, eye care and medications, which is covered by private sectors. The current health care policy is guided by the provisions of the Canada Health Act 1984. Approximately 99% of physicians’ service costs and 90% of hospital care are covered by publicly funded program. Historically, Canada’s health system was dated back to 1867 when the British North American Act was passed, which gave federal government the responsibility to take care of marine hospitals and quarantine. As for the provinces, its responsibility is to manage the local hospitals, asylums, charities and other charitable organizations. To compare with the United States of America, the American government does not have a single payer program, which results in a somewhat less efficient healthcare system. Health care facilities are largely owned and operated by private sector businesses. 58% of US community hospitals are non-profit, 21% are government owned, and 21% are for-profit.