I. Contents
General health status in the past: including the basic information of the patient's birth date, place of birth, native place, residence and nationality, as well as the family history of genetic diseases and infectious diseases.
Past medical history: record the diseases that patients have suffered, including acute and chronic diseases and infectious diseases, such as hypertension, diabetes, hepatitis and tuberculosis. It is necessary to describe the onset, duration and treatment of the disease in detail.
Vaccination history: record the information such as the type of vaccine, vaccination time, vaccination site, etc.
History of surgical trauma: record the surgery and trauma done by the patient, including the name, time, location and cause of the surgery, as well as the location, degree and treatment of the trauma.
Blood transfusion history: record the number, time and reason of blood transfusion.
Allergy history: record the allergic reactions that patients have had, including allergic drugs, food, environment, etc.
Preventive health care: record whether patients have regular physical examination or preventive health care, and whether they have special diet or living habits.
Second, matters needing attention in the collection of past history
Accurately record the personal information and health status of patients.
Ask the patient's medical history, surgical trauma history, blood transfusion history, etc. Pay attention to ask whether the patient has allergic reaction.
For some special diseases, it is necessary to know the patient's family history of genetic diseases and infectious diseases.
For some chronic diseases, it is necessary to know the course and treatment of the patients.
Pay attention to protecting patients' privacy and confidentiality, and avoid revealing patients' personal information and illness.
The importance of past history
1, which is helpful for definite diagnosis:
The diagnosis of many diseases needs to consider the patient's past medical history and symptoms. For example, if the physical examination results are abnormal, it may not be easy to diagnose the disease, which needs to be analyzed in combination with the past medical history.
2. Lock the target:
Knowing the patient's past medical history can help doctors determine the possible causes and diagnostic goals. For example, for patients with a chronic disease, doctors can better understand the progress and possible causes of the disease by knowing their past medical history.
3, make a treatment plan:
Knowing the patient's past medical history can help doctors make more personalized treatment plans. For example, doctors can avoid using certain drugs for patients who are already allergic to them.