Question

What is the importance of past medical history in health assessment and what is the best source of this information. Be specific and give rational for your answer. What is the difference between objective and subjective data and how would you obtain these from a comatose patient. Give examples of each. Alcohol consumption is never encouraged in healthcare, However, there are some exceptional instances when it might be recommended, can you name any instance? Support your answer.

Answer 1

Ans) Medical history: A record containing information about a patient's past and present health status.

- To diagnose a patient's present illness, the physician needs the patient's past and current health information. As a professional medical assistant, it is the responsibility for obtaining this information as part of the medical history and assessment.

- Assessment begins with gathering information to determine the patient's problem or reason for seeking medical care. Typically, you ask standard questions and document the patient's responses during the assessment on preprinted forms or in a manner decided by the physician and outlined in the medical office policy and procedure manual.

The medical history forms used by the office may vary with the practice specialty, most forms are composed of these common elements:

• Identifying data (database)
• Past history (PH)
• Review of systems (ROS)
• Family history (FH)
• Social history (SH)

- This information is confidential and protected by the Health Insurance Portability and Accountability Act, or HIPAA, a federal law that protects the privacy of health information. No one except those directly involved in the patient's care may have access to it without the patient's permission.

Past history: This section addresses the patient's prior health status and helps the physician plan appropriate care for any present illness. Information in this section typically includes allergies, immunizations, childhood diseases, current and past medications, and previous illnesses, surgeries, and hospitalizations.

Importance of medical history:

- Being familiar with the medical history form before beginning the patient interview to promote smooth communication during the interview with the patient to understand the patient's condition thoroughly.

Subjective data consist of information provided by the affected individual.

What patients tells you about their SIGNS AND SYMPTOMS. (Ex. "my head hurts")

Objective data include information obtained by the health care provider through physical assessment, the patient's record, and laboratory studies.
What a nurse observes. For example, Patient is clenching head as if in pain.

1. The primary source; patient
2. A secondary source; data can come from a family member, care giver, medical records. Patient is in a coma, is a child or is a patient who can not speak for them self due to their current state.
All data should be verified.

Alcohol abusea Approaches like contingency management and motivational interviewing are effective means of treating substance abuse in impulsive adolescents by focusing on positive rewards and redirecting them towards healthier goals. Educating youth about what is considered heavy drinking along with helping them focus on their own drinking behaviors has been shown to effectively change their perceptions of drinking and could potentially help them to avoid alcohol abuse. Completely stopping the use of alcohol, or "abstinence", is the ideal goal of treatment.

- The motivation required to achieve abstinence is dynamic; family, friends and health practitioners play a role in affecting this motivation.

- However, some people who abuse alcohol may be able to reduce the amount they drink, also called "drinking in moderation". So in this instance, alcohol consumption in moderation can be recommended.

- If this method does not work, the person may need to try abstinence.