健康评估-问诊-第一节概述课件.ppt

1、 n I itch all over.n My stomach aches.n Im afraid of going to surgery tomorrow.Whats wrong with you?“we“weveve been talking about why you been talking about why you came to see me today.Now Id like to came to see me today.Now Id like to get some information about your own get some information about

2、your own past medical history to see if it has past medical history to see if it has any bearing on your present problem.any bearing on your present problem.How was your health as a child?”How was your health as a child?”护理病历首页护理病历首页科别：病室：床号：住院号：姓名 性别年龄 婚姻民族 职业籍贯 住址文化程度 医疗费用支付形式入院日期 入院方式入院医疗诊断 记录日期病

3、史叙述者 可靠程度主管医生 主管护士病病 史史主诉主诉现病史现病史 既往史既往史既往健康状况：良好、一般、较差曾患疾病和传染病史：无、有（）外伤史：无、有（）手术史：无、有（）预防接种史：无、有（）过敏史：无、有（过敏原：临床表现：）功能性健康型态功能性健康型态健康感知与健康管理营养与代谢排泄活动与运动睡眠与休息认知与感知自我概念角色与关系性与生殖压力与应对价值与信念name sexname sexage marriageage marriagerace occupationrace occupationnative place addressnative place addresscultu

4、re pay formculture pay formdate of admissiondate of admissionway of admissionway of admissionmedical diagnosemedical diagnosedate of recorddate of record describer reliabledescriber reliabledoctor nursedoctor nursenThis is the main component of the history.nDetailed documentation of.nincluding including and and nchronology of the illnesschronology of the illness n For example,if a patient describes pleuritic chest pain,ask about the presence of cough,dyspnoea,fever,haemoptysis,etc.