Term
The examination section of a patients notes includes Three subsections. They are: |
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Definition
History
Systems Review
Tests and measures |
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Term
History subheadings
Demographic information: |
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Definition
Patients Name
address
admission date
date of birth
sex
dominant hand
race
ethnicity
language
Education level
advanced directive preferences
Referral source
reasons for referral to therapy |
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Term
History subheadings;
Current conditions/chief complaints: |
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Definition
onset date of problem
any incident that caused or contributed to the problem
prior history of similar problems
how the patient is caring for the problem
what makes the problem better or worse
other practitioners the patient has seen for the problem
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Term
History subheadings
Patient goals: |
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Definition
Patient/client and sometimes family goals for therapy as told to the therapist by patient or family |
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Term
History subheadings
Prior level of function: |
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Definition
level of function prior to the most recent onset of current complaint
if a chronic condition the function prior to the most recent onset of symptoms |
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Term
History subheadings
social history |
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Definition
cultural and religious beliefs that might effect care
who does the person live with prior to admission
who will the person live with after discharge
available social and physical supports now and after discharge
availability of a caregiver |
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Term
History subheadings
employment status: |
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Definition
does the patient work
full time
part time
Student
work at home/office
retired |
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Term
History subheadings:
Living environment: |
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Definition
assistive devices and equipment the patient uses
type of residence
info about the residence
Steps-stairs-ramps-etc
use of community services such as: home health services, meals on wheels, hospice, homemaking services, other programs
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Term
History subheadings:
General health status: |
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Definition
Patients self rating of general health
any major life changes during preceding year |
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Term
History subheadings:
social/health habits: |
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Definition
smoke
drink
exercise habits
physical activities ie hangliding, base jumping, dancing, etc. |
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Term
History subheadings:
Family health history: |
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Definition
general screening for a family history of
heart diseae,
hypertension,
stroke,
diabetes,
cancer,
psychological conditions,
arthritis,
osteoporosis and
other conditions. |
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Term
History subheadings:
patient medical/surgical history: |
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Definition
Any patient reported medical surgical history |
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Term
History subheadings:
Functional status/activity level |
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Definition
mobility
transfers
gait
selfcare
home management
community, school and work activities
that apply to current condition |
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Term
History subheadings:
Medications: |
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Definition
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Term
History subheadings:
growth and development: |
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Definition
most applicable to pediatrics
include developmental history |
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Term
History subheadings:
Other clinical testsL |
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Definition
other clinical tests the dates and findings of those tests. |
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Term
It is unnecessary to report the source of the information in the history section uless it |
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Definition
contradicts information given by another source
or
it is the patients belief and not factual or documented medically |
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