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Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
[citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]
Example. A practitioner typically asks questions to obtain the following information about the patient: Identification and demographics: name, age, height, weight.; The "chief complaint (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
P – Patient, problem or population; I – Intervention; C – Comparison, control or comparator [6] O – Outcome(s) (e.g. pain, fatigue, nausea, infections, death) An application that covers clinical questions about interventions, as well as exposures, risk/ prognostic factors, and test accuracy, is: [7] [8] P – Patient, problem or population
The assessment will also include possible and likely etiologies of the patient's problem. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the ...
The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilised, and patient's condition deteriorated. In the event where the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step.
[1] [2] Patients observe these symptoms and seek medical advice from healthcare professionals. Because most people are not diagnostically trained or knowledgeable, they typically describe their symptoms in layman's terms, rather than using specific medical terminology. This list is not exhaustive.
Though manuals like the DSM have covered a lot of ground when it comes to defining mental illnesses, in some disorders the reliability of diagnosis is still very poor. For example, inter-rater reliability in cases of dementia is very high, with a kappa value of 0.78, while major depressive disorder is often diagnosed differently by independent experts who see the same patient, with a kappa ...