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The nurse Takes a Patient's Medical History

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Medical History

Medical History is a collection of information obtained from the patient and from other sources concerning the patient's physical status as well as his or her psychologic, social, and sexual function. The history provides a database on which a diagnosis, a plan for management of the diagnosis, treatment, care, and follow-up observation of the patient may be made.

The first part of the history describes the chief complaint; the history of the present illness, including its signs and symptoms, onset and character; and any factors or behaviors that aggravate or ameliorate the symptoms. The patient's own words often serve as the best description and may be quoted.

The second part of the history comprises an account of previous illnesses and health-promotion behaviors, allergies, transfusions, immunizations, screening tests, and hospitalizations. An occupational history, describing the patient's work and exposure to stress, toxins, radiation, or other occupational hazards, may be included. The effect of the current illness on the patient's work is also noted.

A social history is taken in which the patient's social, cultural, environmental, and familial milieu are outlined, focusing on aspects that might have an effect on the current illness. In some instances a sexual history may be relevant.

A review of systems may follow or be incorporated into the health history. Kinds of history include complete health history, episodic health history, and interval health history. Also called functional assessment. See also family history, occupational history, past health, personal and social history, present health, review of systems, sexual history.


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