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It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
The glucose tolerance test was first described in 1923 by Jerome W. Conn. [4]The test was based on the previous work in 1913 by A. T. B. Jacobson in determining that carbohydrate ingestion results in blood glucose fluctuations, [5] and the premise (named the Staub-Traugott Phenomenon after its first observers H. Staub in 1921 and K. Traugott in 1922) that a normal patient fed glucose will ...
The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken.
In cases in which a physician has difficulty explaining complicated medical concepts to a patient, that patient may be inclined to seek information on the internet. [8] A consensus exists that patients should have shared decision making, meaning that patients should be able to make informed decisions about the direction of their medical treatment in collaboration with their physician. [9]
The Patient Health Questionnaire 2 item (PHQ-2) is an ultra-brief screening instrument containing the first two questions from the PHQ-9. [ 8 ] : 3 Two screening questions to assess the presence of a depressed mood and a loss of interest or pleasure in routine activities , and a positive response to either question indicates further testing is ...
The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.
The standards allow for easier 'interoperability' of healthcare data as it is shared and processed uniformly and consistently by the different systems. This allows clinical and non-clinical data to be shared more easily, theoretically improving patient care and health system performance. [1]