Collection and Documentation of Health History
Purpose of Health record
Health history or health record is a systematically created document which stores the complete history of the diseases and physical conditions of the patient. This document gives a chance to the physicians to understand the complete background of patient’s physical health and helps them to plan their further strategy for the treatment of the patient.
This document also provides an opportunity to educate medical students and to provide data for medical research (Makoul, 2003). Health history is the first and foremost part of any medical examination. This data helps the physician to understand the physiological, psychological and sociological problems of the patient and gives a clue to the physicians for their treatment (Desmond & Copeland, 2000).
Components of Effective Health History
The complete medical history, with slight variations, may consists of:
• Biographical data: it consists of information regarding patient’s personal life. It helps to determine the cultural background of the patient through which the physician can identify any specific need and belief that may affect the health of the patient. The information regarding patient’s education and status helps to determine his strengths and weaknesses and the factors which may affect his / her health. For example if a patient holds a high profile position, maybe the stress of the job is the major cause of the disease etc.
• Present disease: this part describes the current health problem of the patient and why he or she wants to seek the health care
• History of present disease: this part provides the detail of the current health problem like how the problem started, what are the symptoms, what makes it worse or better, what are the treatment taken so far etc.
• Previous health history: this section helps the physicians to determine the causes or factors of present problem
• Family history: Medical research has proved that most of the diseases stem from the family medical history. Similarly some of the present problems which may affect patients’ health like habit of incessant smoking may be caused due to grown up in a family of chain smokers etc.
• Review of Body Systems (ROS) for present disease: in this section, each body system is reviewed in order to identify the causes of present health problem
• Lifestyle: this section describes the life style, the eating habits, exercise pattern, drinking and smoking habits etc. of the patient. Lifestyle usually play an important role in the diagnosis and treatment of the disease
• Social Data: this section gives complete information about the educational and social status of the patients, their friendships and relationships, occupational history, neighborhood etc.
• Psychological Data: what are the major worries and pressures faced by the patient and how do he / she cope with these pressures etc.
• Patterns of Health care: it gives the details of the...