Medical assistants are responsible for documenting and maintaining patient health records. These records detail the evaluation, management, and treatment given to the patient. Patient records are critical to the patient's care. WIthout accurate and complete patient records, medical care can easily be compromised with the potential for (unintentional) harm to the patient. Show Past health history Past health history includes the patient's past illnesses such as childhood illnesses, accidents, hospitalizations, and operations. Because the patient is describing a past accident, it should be documented under the past health history section. The patient is not mentioning any signs and symptoms; therefore, this should not be included in the reason for seeking care section. The patient is not mentioning present health status; therefore, this should not be included in the history of present illness. The patient does not mention daily activities; therefore, this should not be included under the "functional assessment" section. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses. Musculoskeletal system The review of body systems records the past and present health status of each body system. In the musculoskeletal system, the problems associated with the muscles and the skeleton, such as muscle pain, cramps, gait problems, and back pain, are included. In the endocrine system, the symptoms and history of endocrine disorders such as diabetes and thyroid gland disorders are recorded. In the neurologic system, motor functions, cognitive functions, sensory functions, and mental status are included. In the peripheral vascular system, the symptoms associated with the obstruction of blood flow in the arteries and veins are included. Recommended textbook solutions
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What kind of information is included in a patient's medical history?A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
What information should be included in a patient's medical records quizlet?Information on a patient such as, demographics, progress notes, problems, medication, vital signs, past medical history, immunizations, laboratory data, radiology pictures, and other personal data (height, weight, and billing information). Information that is provided by the patient and then updated as necessary.
Which data would be included in a health history quizlet?The review of systems, sexual history, nutritional assessment, and family medical history are part of the health history.
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What information would be included in the patients personal medical history quizlet?
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