病史的作用
病史的作用
病史是醫(yī)生將與病人或知情人交談中采集到的病情或有資料整理編排后所作的記錄。接下來小編為大家整理病史的作用，希望對你有幫助哦!
A detailed patient history and physical exam form the foundation of patient evaluation and vital patient data that enables efficient, quality patient rounds.
On the other hand, a poorly documented history and physical may leads to confusion, serious omission of vital data and inefficiency on patient rounds. In this age of modern technology with equipment such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a past era! Both attending physicians as well as residents in training seem to rely more heavily on laboratory and imaging modalities than history to establish the diagnosis. “However no part of the patient evaluation is more essential to diagnosis than the patient history. The importance of skillful data collection is underscored by the widely accepted understanding that the medical history contributes 60% to 80% of the information needed for accurate diagnoses.” Thus to neglect the patient history denies the physician of a “vital” diagnostic tool.
The basic outline structure for the patient history and physical exam usually includes the following:
l Identification: patient name, age, gender, race, and occupation
l Chief Complaint: (in the patient's words)
l HPI: (history of present illness)
l PMHx: (past medical history)
l Medications: should include current meds as well as medication allergies
l ROS: review of systems
l Social Hx.: includes family situation (married, divorced, single), habits; cigarettes, alcohol or illicit drug use, sexual behavior
l Physical Exam:l Impression/Diagnosis:lTreatment Plan:
l Self- introduction: Upon arrival at the patient's bedside, the physician should first try to establish rapport with the patient by using “nonverbal cues” such as maintaining eye contact or extending a hand to shake the patient's hand (if “culturally” acceptable). The physician or student should first introduce him or herself and state their reason for the visit. Also, they should ask the patient's permission to interview them.
Here are a few specific points about each section of the history outline:
1. Identification -- This should include the patient's name, age, sex, race and occupation for example: “Mr. Jones is a 55 yr. Old Caucasian male who works as a farmer.” The patient's name written in the history allows future interviewers to address the patient by his name which conveys a sense of patient respect. The age, race, sex and occupation are an important as many diseases are not only gender and age dependent, but may also occur more commonly in specific ethnic and occupation groups.
2. Chief complaint -- This should be written in the patient’s words. For example “chest pain” rather than “angina”. Also the duration of the chief complaint should be noted “chest pain for 1 hour”. Before moving on to the HPI, it would be appropriate to perform a “survey of problems” asking the patient if there are any other current problems bothering them. Once these have been listed, the interviewer can come back to the original Chief Complaint the patient presented with and obtain the details in the HPI. However “associated” symptoms should be descried in the HPI.
一份詳細的病史和體檢是評估患者的基礎(chǔ)，也可為組織高質(zhì)量、高效率的查房提供重要的資料。
另一方面，寫得差的病史和體檢可能會引起混淆，導致重要資料的遺漏和查房效率的低下。在這個具有現(xiàn)代化設(shè)備如CT、MRI、PET的年代里，病史和體格檢查似乎已慢慢地成為一種歷史遺物。無論是主治醫(yī)生或住院醫(yī)生都似乎越來越依賴于實驗室和影像學檢查而不是病史來明確診斷。然而對診斷來說，沒有一種評估手段比病人的病史更重要。盡管普遍認為病史可提供準確診斷所需的60%一80%的信息，但有效地收集資料的技能仍被低估了。所以若忽略了患者的病史就意味著剝奪了醫(yī)生的一種最重要的診斷工具。
病史和體格檢查的基本框架內(nèi)容通常包括以下內(nèi)容：
l 身份證明：患者姓名，年齡，性別，種族和職業(yè)
l 主述：(用患者的話表達)
l HPI：現(xiàn)病史
l PMHx：過去史
l 藥物史：包括現(xiàn)在使用的藥物以及藥物過敏史
l ROS：系統(tǒng)回顧
l 社會史：包括婚姻狀態(tài)(已婚、離婚、單身)、習慣、吸煙、飲酒或吸毒、冶游史
l 體格檢查：
l 診斷：
l 治療方案：
l 自我介紹：到達病人床邊時，醫(yī)生應(yīng)通過非言語的方式如保持視線的接觸或伸手去和病人握手(如果風俗上可以接受)來與病人建立融洽的關(guān)系。醫(yī)生或醫(yī)學生首先應(yīng)自我介紹并解釋來看病人的原因，并且應(yīng)在交流前取得病人的同意。
以下是病史相關(guān)部分的說明：
1.身份證明--這應(yīng)該包括病人的姓名、年齡、性別、種族和職業(yè)。比如“瓊斯先生是一位55歲的白人男性，職業(yè)是農(nóng)民”。在病史中寫明患者的姓名有利于以后的人員用病人的姓名來和他打招呼，這樣會使病人產(chǎn)生一種受尊重感。年齡、種族、性別、和職業(yè)都非常重要，因為許多疾病不僅與性別和年齡有關(guān)，并且在特定的種族或職業(yè)人群中更為常見。
2.主述--主述應(yīng)該用病人的語言來寫。比如“胸痛”而不是“心絞痛”。而且應(yīng)同時寫明主訴的時間如“胸痛1小時”。在開始采集現(xiàn)病史之前，應(yīng)補充問病人是否還有其他不適癥狀。一旦發(fā)現(xiàn)有其他癥狀應(yīng)補充到主訴中，并在現(xiàn)病史中詳細描述。但伴隨癥狀應(yīng)在現(xiàn)病史中描述。