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1、HISTORYRECORDWhatishistoryrecordTheclinicalrecorddocumentsthepatient'shistoryandphysicalfindings.Itshowshowcliniciansassessthepatient,whatplanstheymakeonthepatient'sbehave,whatactionstheytake,andhowthepatientrespondstotheirefforts.Importanceofhistoryrecord1.
2、DiagnosisandtreatmentpurposeAnaccurate,clear,wellorganizedrecordreflectsandfacilitatessoundclinicalthinking.Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient2.Teachingandresearchpurpose3.MedicolegalpurposesHowtomakeagoodh
3、istoryrecordWhencreatingarecord,youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination.Youmustreviewyourdata,organizethem,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,yetcomprehensivereport.Howtomakea
4、goodhistoryrecord1.Orderisimperative2.Keepitemsofhistoryinthehistory3.Describespecificallyanypertinentnegativeinformation4.Datanotrecordedaredatalost5.Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething6.Beobjective7.Youshouldwritetherec
5、ordassoonaspossibleBasicrequirementforthehistoryrecord1.Tobewellorganizedandcanonical2.Nomucherasionandgridecouldbedoneinthehistoryrecord3.Tobeobjectiveandaccurate4.Usingprofessionaltermtorecordinsteadoffolksay5.RemembertohaveyoursignatureA.Outlineofcasereco
6、rd1.BiographicaldataBiographicalinformationofpatientshouldincludehisfullname,age(dateofbirth),sex,race,occupation,nationality,maritalstatusandpermanenthomeaddress.Also,thedateofadmission,thetimeatwhichyoutookthehistory,thesourceofhistoryandestimateofreliabil
7、ityshouldbeinvolved.2.chiefcomplaintThechiefcomplaintconsistsofmainsymptom(s)andduration.Itshouldconstituteinafewsimplewordsthemainreasonswhythepatientconsulteddoctorandshouldbestateasnearlyaspossibleinthepatient’sownwards.Ingeneral,thechiefcomplaintshouldin
8、cludeage,sex,complaint,anddurationofthecomplaint.Itshouldnoincludeddiagnostictermsordiseaseentities.Forexample:”This70-yearoldmanhashadshortbreathforaweek.”3.Historyofpresentillness(HPI)Thehisto
