Past Health History

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

Health history of a patient is an important tool in identifying health issues and devising efficient interventions to address them. Hence, health providers can use health history information to diagnose, treat and plan for the care of the patients (Ball et al., 2006). In that light, we will focus on the patient named BB for purposes of privacy and confidentiality. BB is a 70-year-old Caucasian female. The patient resides and recently just moved to Show Low, Arizona. She is married and operates her business with the help of her husband. The interview was conducted at her home in Show Low, Arizona. More importantly, the patient's consent was sought before this meeting and she was assured of the confidentiality of the information 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).

ANSWER: The type of information that is gathered is marital status and/or living arrangemet, current employment, occupational history, any use of drugs, alcohol and/or tobacco, level of education, and sexual history. These questions are relevant just incase the lifestyle the patient is living has contributing factors of the patients illness. This will provide more information and can assist in the diagnosis.

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.

The medical history is used to guide the treatment for any contraindications, medical concerns, and side effects

This paper assignment explain how important is to get a full medical and health history including ear and thyroid assessment to get a better outcome in patient disease and management to prevent more serious complications.

Changing the dressing: be sure all the necessary supplies are ready, perform hand hygiene; scrub the hand for at least 15 seconds to get rid of germs. With non-sterile gloves remove the old dressing making sure not to touch the line under the dressing. Assess the site for redness, drainage, pus, or swelling which are signs of infection. With instructions on the procedure, using sterile technique put a new dressing. (University of Virginia, 2015)

Problem lists are used to track both acute and chronic conditions related to the care of the patient (Garlee, 2012). The purpose of the problem list is to ensure that everyone who touches the patient knows what conditions are present (Garlee, 2012) The problem list is important because it ties everyone involved in providing health care all understand the same circumstances that exist to prevent medical errors. It is stated in the text, that all clinic staff should be able to easily see the current problems for a patient and view the history of problems. Please note, that the conclusion or diagnosis is not a problem to be listed in the problem list portion of the patient medical record. It is important to not confuse diagnosis with problems, they are not the same. The problem list is important because it is an updated version of the current status of the patient. The problem list is always updated during each patient visits to the doctor, and prior to any blood work or procedures are done on patients. The problem list is also important because symptoms are liable to change or fluctuate in between doctor visits. That is why problem list are update every doctors visit. Problem list can be viewed to see what symptoms are trending and what symptoms are regressing. Problem list are important in this sense so health care providers can prioritize patient symptoms as those that are trending to become top priority and those that are fading away to be low priority.

Do not soak your stump in a warm or hot bath for longer than 20 minutes at a time.

Forms of violence and trauma resulting from the Indian Act during colonization are embedded in social determinants of health and are directly linked to a disproportionate burden of illness. Before colonization, Indigenous communities had ‘subsistence cultures’, which means that nutrition, diet, and medication were provided through their local ecosystem (Richmond & Cook, 2016, p. 3). During colonization by European settlers in Canada, conflicting ideologies about ways of living caused challenges between the Indigenous and Europeans (Richmond & Cook, 2016, p. 3). The need to manage Indigenous populations took the form of the Indian Act of 1867, which gave the federal

Patient believes health is definitely important and visits his doctor when problems persist or are troubling.

The proband interviewed is a 53-year-old female. Based on the family history given by the proband, the pedigree formed interprets that there are multiple diseases that are common within the family. Even though the proband has already been diagnosed with hypertension, diabetes and high cholesterol, there are still opportunities to reduce the effects of these diseases and improve health along with lifestyle. The information on family history also promotes an opportunity for the proband and significant other to guide their children in a better direction to prevent the common diseases in the family.

Respiratory Assessment for Nurses outlined the importance of appropriate respiratory assessment to improve care outcomes for the acutely ill ward patient. It is recognized that deterioration in physiological status is often not appreciated, nor acted on in a timely manner (Considine and Botti 2004). The anterior posterior diameter of the chest has a ratio of 1:2. Normal breathing is silent, regular, symmetric, and rhythmic and occurs at a rate of 12 to 20 times per minute (Jarvis, 20 The 4 major components of the lung exam (inspection, palpation, percussion and auscultation). Learning the appropriate techniques at this juncture will therefore enhance your ability to perform these other examinations as well. A student nurse completed a

According to Bickley (2012) a comprehensive health history, which is often refer to as a complete health history is the collection of certain health information that is unique to that individual. This information is usually collected in an organized manner and consists of seven components. These components are, identifying the data and the data source/reliability, chief complaint, present illness, past history, family history, person and social, and review of systems (Bickley, 2012).