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It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
Each letter stands for an important line of questioning for the patient assessment. [ 3 ] [ 4 ] This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note , for later reference.
The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical (a.k.a. the H&P). The history requires that a clinician be skilled in asking appropriate and relevant questions that can provide them with some insight as to what the ...
A patient agrees to a health intervention based on an understanding of it. The patient has multiple choices and is not compelled to choose a particular one. The consent includes giving permission. These practices are part of what constitutes informed consent, and their history is the history of informed consent.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.
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In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details. Much of the history is obtained by asking questions.