Description about topics
Patient history
This page allows you to record patients' medical histories and physical status, which aids in diagnosis and treatment. It includes long- and short-term goals, proposals for further action, and other relevant details. All this information can be recorded electronically in PDF or JPG format or printed for physical records.
Providing your primary care provider with a thorough medical history gives them a better understanding of your overall health. It enables your medical practitioner to identify patterns and make more effective decisions tailored to your specific health needs.
This process also allows your practitioner to assess your risk for certain diseases or conditions. It can help prevent the onset of health problems. For example, if you have a family history of diabetes, your doctor will know to monitor you closely for prediabetes. Similarly, your practitioner may order tests or screenings if you are at higher risk for certain chronic complications.
Your practitioner will work with you to establish a plan to stay healthy and reduce your risk of developing preventable diseases.
Muscle force over joints:
Normal sensibility for pain, touch, and temperature.
Normal walking, standing on heels and toes, and rising up.
• name, address, date of birth, referring practitioner
Chief physical complaints
Social status
• occupation, family, daily function, ... Medical history
a) Family illnesses – parents, siblings, children
b) Prior illnesses – in chronological order. Duration, treatment, complications
c) Present illnesses – onset, symptoms, course of symptoms, present status
Upper extremities
Lower extremities
Force
Muscle force over joints:
Shoulders, elbows, fist, hip, knee, ankle
Coordination
Normal sensibility for pain, touch and
Temperature Balance and walking
Normal walk, stand on heels and toes, rise up
History should be Focus on physical
examination which include
Present illness,
Describe the case in a narrative form.
Present illness as well as medical history must be listed.
Include the important details of your current problem.
The patient relies entirely on your clinical judgment and defers all decisions to you.
The patient wants the problem resolved immediately and is unwilling to consider alternative treatment options.
The patient wants to avoid surgery at all costs and prefers non-invasive approaches.
Patient Feedback
In this page patients feedback can be done. This will help to record in short progress reports of patients . These all details can be recorded electronically in pdf or jpg format or can be printed out.
Through this page patient treatment effectiveness can be recorded.Further treatment is needed or not needed ?
Chief physical complaints and importance feedback
This page helps to assess the database. It provides an overview of the more commonly seen signs and symptoms and their corresponding diagnostic findings.
Establishes a general ranking of needs and concerns on which the nursing diagnoses are ordered in constructing the plan of care. This can be altered according to the individual client's situation.
Identifies short-term and intermediate goals to be achieved by the client before being "discharged" from nursing care. They may also provide guidance for creating long-term goals for the client to work on after discharge.
The general need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added to create a client diagnostic statement when specific client information is available. For example, when a client displays increased tension, apprehension, a quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated as: Severe Anxiety related to unconscious conflict and threat to self-concept, as evidenced by statements of increased tension and apprehension, and observations of a quivering voice and focus on self.
In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted, and new diagnoses added, depending entirely on the specific client information.
These lists provide the usual or common reasons (etiology) why a particular need or problem may occur, along with probable signs and symptoms, which would be used to create the "related to" and "evidenced by" portions of the client diagnostic statement when the specific situation is known.
When a risk diagnosis has been identified, signs and symptoms have not yet developed and therefore are not included in the nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The exception to this occurs in the nursing diagnosis Risk for Violence, which has possible indicators that reflect the client's risk status.
Nursing Interventions Classification (NIC) labels are drawn from a standardized nursing language and serve as a general header for the nursing actions that follow.
The interventions in this book are generally ranked from most to least common. When creating the individual plan of care, interventions would normally be ranked to reflect the client's specific needs and situation. In addition, the division of independent and collaborative interventions is arbitrary and is actually dependent on the individual nurse's capabilities, as well as hospital and community standards.
This abbreviated plan of care or care map is event- or task-oriented and provides outcome-based guidelines for goal achievement within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.
On this page, the patient's history for physical status can be recorded. This will help in the diagnosis and treatment of patients, which includes long- and short-term goals, proposals for further action, etc. All these details can be recorded electronically in PDF or JPG format, or they can be printed out.
Providing your primary care practitioner with this information gives him or her a better understanding of your health. It allows your medical practitioner to identify patterns and make more effective decisions based on your specific health needs.
This allows your practitioner to assess your risk for certain diseases or conditions. It can also help prevent the onset of certain health problems. For example, if you have a family history of diabetes, your doctor will know to look closely for prediabetes. Alternatively, your practitioner may order tests or screenings if you have a higher risk for certain types of chronic complications.
Your practitioner will work with you to establish a plan to stay healthy and decrease your risk of developing certain diseases.
Document your medical history and share this information with your practitioner, including:
Muscle force over joints:
Normal sensibility for pain, touch, and temperature
Muscle stiffness treatments are dependent upon the cause. Muscle stiffness due to overuse of skeletal muscle will eventually disappear on its own, or common home treatments will help.
Resting the muscles, or applying ice packs and heating pads, stretching, or lightly massaging the muscle.
After 48 hours, local medical advice should be sought.
Muscle stiffness can be diagnosed through:
Physical therapists and related professions often use muscle testing.
Muscle testing is used to determine:
Mental symptoms of anxiety can include:
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