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1、HISTORYRECORDWhatishistoryrecordTheclinicalrecorddocumentsthepatient'shistoryandphysicalfindings.Itshowshowcliniciansassessthepatient,whatplanstheymakeonthepatient'sbehave,whatactionstheytake,andhowthepatientrespondstotheirefforts.Importanceofhistoryrec
2、ord1.DiagnosisandtreatmentpurposeAnaccurate,clear,wellorganizedrecordreflectsandfacilitatessoundclinicalthinking.Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient2.Teachingandresearchpurpose3.MedicolegalpurposesHowto
3、makeagoodhistoryrecordWhencreatingarecord,youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination.Youmustreviewyourdata,organizethem,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,yetcomprehensivere
4、port.Howtomakeagoodhistoryrecord1.Orderisimperative2.Keepitemsofhistoryinthehistory3.Describespecificallyanypertinentnegativeinformation4.Datanotrecordedaredatalost5.Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething6.Beobjective7.
5、YoushouldwritetherecordassoonaspossibleBasicrequirementforthehistoryrecord1.Tobewellorganizedandcanonical2.Nomucherasionandgridecouldbedoneinthehistoryrecord3.Tobeobjectiveandaccurate4.Usingprofessionaltermtorecordinsteadoffolksay5.Remembertohaveyoursig
6、natureA.Outlineofcaserecord1.BiographicaldataBiographicalinformationofpatientshouldincludehisfullname,age(dateofbirth),sex,race,occupation,nationality,maritalstatusandpermanenthomeaddress.Also,thedateofadmission,thetimeatwhichyoutookthehistory,thesource
7、ofhistoryandestimateofreliabilityshouldbeinvolved.2.chiefcomplaintThechiefcomplaintconsistsofmainsymptom(s)andduration.Itshouldconstituteinafewsimplewordsthemainreasonswhythepatientconsulteddoctorandshouldbestateasnearlyaspossibleinthepatient’sownwards.
8、Ingeneral,thechiefcomplaintshouldincludeage,sex,complaint,anddurationofthecomplaint.Itshouldnoincludeddiagnostictermsordiseaseentities.Forexample:”This70-yearoldmanhashadshortbreathforaweek.”3.Historyofpresentillness(HPI)Thehisto
