Collection and Documentation of Health History - 1549 Words

Collection and Documentation of Health History Purpose of Health record Health history or health record is a systematically created document which stores the complete history of the diseases and physical conditions of the patient. This document gives a chance to the physicians to understand the complete background of patient’s physical health and helps them to plan their further strategy for the treatment of the patient. This document also provides an opportunity to educate medical students and to provide data for medical research (Makoul, 2003). Health history is the first and foremost part of any medical examination. This data helps the physician to understand the physiological, psychological and sociological problems of the patient†¦show more content†¦The basic requirements for extracting detailed information from client are: 1. The health care professional must be perfectly aware of his / her communication style and 2. Have the ability to modify his / her style in order to get better interaction and acquaintance with the patient (Gerteis, Edgman-Levitan, Daley et al., 1993) Like all other human interactions, first impression plays an important role in medical interaction also. Thus, it is important to give full attention to the patient by greeting the patient with his / her name and give a personal touch to the interaction, focus the attention towards his / her chart and listen attentively what the patient is saying. This personal touch to the interaction will help to melt the ice between the patient and the health care professional and makes the patient more communicative (Baker, 1998). Body Language Nonverbal communication plays more important part in communication than verbal communication because language and other methods of communication, which are appropriate in one semantic environment, are usually not utilized in another semantic environment. For example in playgrounds and sports, children use the expressions like â€Å"game plan† or â€Å"Captain of the ship† which cannot be used in a different semantic environment for example workplace. Many of the rules of discourse in a semantic environment are based on situational regulations of behavior. Rules of discourse in a specificShow MoreRelatedHistory Of Medical Record Keeping Documents754 Words   |  4 PagesThe history of medical record keeping documents have been traced back to Ancient Egypt around 1900BC to 1500BC. As Egyptian priests or physicians would make new discoveries about the human anatomy, they would document the findings on thick pieces of paper like fabric that was made from the vascular tissue or pith of the Cyperus papyrus plant known as papyri. During the medieval era of Europe, Physicians were known to document patient diet recommendations, successful treatment plans, and surgicalRead MoreNature Of Human Tissue Specimens Within Museum Collections1526 Words   |  7 Pagesthat some of the information obtained is anecdotal oral history and cannot be verified through documentation. Within the last twenty years, the controversial nature of human tissue specimens within museum collections has sometimes led to their disposal, and the erosion of technical conservation skills relating to this particular type of collection. 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Both computers and EHRs canRead MoreThe Electronic Health Records ( Ehrs ) Essay1644 Words   |  7 PagesClinical Documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy and to direct care of the patientRead MoreAdvantages And Importance Of A Health Assessment779 Words   |  4 Pagesregarding a health assessment, and the scope within the term Health Assessment; while including the elements involved to achieve a measurable outcome and supportive validation of a person’s wellness. 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These vital informationsprovide a conceptual baseline data utilized in developing nursingdiagnosis, subsequent plans for individualized care and for the nursingprocessRead MoreRisk Management Nursing Documentation Nur 4921008 Words   |  5 PagesRisk Management Nursing Documentation Oscar Chavez NUR 492 May 4, 2012 Susan Dean, RN, MSN, FNP Risk Management Nursing Documentation The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities