Health History Essay

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

Areas of red skin that doesn’t go away when pressure applied, sore skin, dry skin, hot or cold areas of skin, blisters or broken skin should all be reported. Discoloured skin should also be reported.

No neck swelling. Denies history of seizures or dizziness. Patient admits to headaches especially when blood pressure is not controlled.

HISTORY AND PHYSICAL EXAMINATION_______________________ Patient Name: Chapman Robert Kinsey Patient ID: 110589 Room No.: 322-B Date of Admission: 23 February ---Admitting Physician: Martha C. Eaton, MD, Geriatrics Chief Complaint: Admitted from Dr. Max Hirsch’s office due to deep ulcer on left toe. Admitting Diagnoses 1. Severe peripheral vascular disease, status post deep ulcer on left toe. Rule out thrombolysis. The patient was admitted to a regular floor. Condition is serious. 2. ALLERGY TO PENICILLIN, which puts patient into anaphylactic shock. 3. Continue with home medications. DETAILS OF PRESENT ILLNESS: Mr. Kinsey is an 87-year-old white gentleman with history of (1) Chronic atrial fibrillation, on Coumadin. (2) Chronic deafness,

I have gained full consent to use this lady as my patient in my care study. Consent is important as you must always gain permission from the patient in regards to their care plan and keep them fully informed. ‘It is vital that the person consents before any treatment, care, examination or assessment’ (Brooker et al., 2007, p.157). ‘Confidentiality is a fundamental part of professional practice that protects human rights’ (NMC, 2008). To maintain my patient’s confidentiality throughout my care study I am going to call her Annie. Annie is a 72 year old lady whose care I have been involved with on placement. Annie’s medical history included; previous left hip replacement, osteoporosis, high blood pressure, high cholesterol and

On assessment, the wound was slightly exudates, odour, sloughs and dry skin patches on the surroundings. Sprakes (2010) state that, holistic assessment of patient and the wound are essential in order to facilitate the wound healing process. Ousey and McIntosh (2010) points out that, chronic wounds are exacerbated by a sequence of misdiagnosis, neglect, incompetence or inappropriate treatment strategies. I observed that, M’s wound was with exudates and sloughs; this

The information contained in the medical records is confidential and can only be released to authorized individuals in accordance with state and federal regulations. At Consulate Health Care only authorized persons may have access to clinical records in the permanent record file. Specifically authorized personnel are those involved in resident care, the Executive Director, consultants employed by the Facility, appropriate representatives of survey agencies, and others engaged in research projects who have been approved by the Executive Director. As a health care provider, Beneva Lakes’ primary focus of Health Insurance Portability and Accountability Act, HIPAA, is: Combating against fraud and abuse; Ensuring confidentiality and security of individuals’ information/data; and Mandating uniform standards for electronic data transmissions of patient health information. Sharing Protected Health Information, PHI, is allowed for the purposes of treatment, billing, health care operations, determining eligibility and with patient authorization. Any sharing of PHI not required or allowed by federal of state statute is improper and it must be properly maintained for at least ten years. It is Consulate Health Care’s policy that prior to releasing PHI for promotional purposes, the provider must receive a written authorization that includes the dates it is valid and the ability of the patient to revoke the authorization.

Refer to the course textbook for detailed components of each system exam. Remember, assessment of the integumentary system is an integral part of the physical exam and should be included throughout each system.

This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration.

“The Health Insurance Portability and Accountability Act (HIPAA) of 1996 made it illegal to gain access to personal medical information for any reasons other than health care delivery, operations, and reimbursements” (Shi & Singh, 2008, p. 166). “HIPAA legislation mandated strict controls on the transfer of personally identifiable health data between two entities, provisions for disclosure of protected information, and criminal penalties for violation” (Clayton 2001). “HIPAA also has privacy requirements that govern disclosure of patient protected health information (PHI) placed in the medical record by physicians, nurses, and other health care providers” (Buck, 2011). Always remember conversations about a patient’s health care or treatment is a violation of HIPAA. “All PHI is included in the privacy requirements for example: the patient’s past, present or future physical or mental health or condition; the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual” (Buck, 2011). Other identifiable health information would be the patient’s name, address, birth date and Social Security Number (Keomouangchanh, 2011). (Word count 197)

Medical history records of a patient could reveal a history of mental illnesses, depression or other conditions. In an event that these people were to lose health insurance, they may find it impossible to obtain a private health insurance outside due to their pre-existing medical condition.

The practice of medicine has been shaped through the years by advances in the area of diagnostic procedures. Many of these advances were made possible by scientific breakthroughs made before the 20th century. Modern medicine arguably emerged. Both normal and abnormal functions (physiology and pathology) were increasingly understood within smaller units, first the tissues and then the cells. Microscopy also played a key role in the development of bacteriology. Physicians started to use stethoscope as an aid in diagnosing certain diseases and conditions. New ways of diagnosing disease were developed, and surgery emerged as an important branch of medicine. Above all, a combination of science and technology underpinned medical knowledge and

From information contained in the patient’s social services, medical, and legal records, the clinician is able to piece together Mr. Y’s history.

If you have experienced sudden ringing in ear, then you may have a condition called tinnitus. This is a condition that affects around 20 percent of adults. It is often a sign of an underlying problem, such as a circulatory problem or ear injury. It may also be a sign of hearing loss.

Atypical forms
 Atypical forms are frequent. Many unusual localizations have been recorded,including digital and interdigital forms. Verrucous lesions partic- ularly affect the legs. A follicular form, especially in children, may be confused with pityriasis rubra pilaris. A lichenoid variety has been reported to involve the flexures or the extremities in a ‘glove and stocking’ distribution (Ploysangam and Mutasim, 1997)