Doctor
Gathering a patient's medical history and giving a physical examination can be important parts of both routine office visits and checkups as well as in emergency situations. Both aspects of routine patient care can help to diagnose any current injuries, illnesses or conditions. Knowing the different aspects of proper patient care, and being able to place them in a formal structure, can help to give the best possible services as a medical provider.
Patient Medical History
The patient's medical history is a list of pertinent history related to the patient. In the doctor's office, the medical history is gathered covering nearly all of the procedures or ailments that the patient has experienced during her lifetime. However, during an emergency situation, medical history is limited to only that which is most pertinent. For example, if someone has a laceration and she is also a hemophiliac, then that is pertinent to her current situation, because her body is unable to use platelets to form blood clots. However, if someone has a laceration and has had her tonsils removed, then that is not pertinent to the emergency at hand.
When to Gather Medical History
In a doctor's office, medical history is usually collected in the waiting room using a form on which the patient records all previous allergies, ailments, conditions and surgeries. Then, once a patient is escorted to the examination room, a nurse will give an initial assessment examination and collect more in-depth pertinent medical history before the doctor comes into the room. This way, the doctor has much of the necessary information about the patient, thereby maximizing his time and efficiency to see and treat patients.
In an emergency setting, medical history is taken after an initial assessment of the scene and a patient is determined to not be in any life-threatening condition that could prevent breathing or circulation of the blood. The patient history is taken after a head-to-toe exam and signs and symptoms are reported.
Patient Examination
The patient examination is a thorough, hands-on approach to assessing the patient. It differs from the patient's medical history as part of the procedure that involves physically touching the patient rather than collecting verbal information. The physical exam seeks to prod the patient to discover the exact nature of his condition according to observations made by the nurse, doctor or first responder. Sometimes, patient examinations may reveal a new set of information that the patient was unaware of at first.
When to Give a Patient Examination
The patient examination is given after the initial assessment is complete and preliminary information is gathered, which may include a medical history unless it is an emergency situation. In a doctor's office, the patient examination can occur when the nurse is servicing the patient and then again when the doctor provides services. In an emergency setting, a full head-to-toe exam is given after a rescuer or first responder gives an initial assessment to make sure that the patient is not suffering from any life-threatening conditions, such as a blocked airway or excessive bleeding. The head-to-toe exam is meant to help reveal any other conditions that the patient may be suffering from, but does not report. In emergency situations, this may occur because the pain of the initial complaint is masking other conditions that may be present.
Significance
Both the medical history and the patient examination help to gather information for use during treatment. The more information that can accurately and efficiently be gathered about a patient, the greater the likelihood that a patient will receive successful treatment, whether in a doctor's office or in an emergency room. The medical history allows the patient to give relevant information that might otherwise be apparent through routine physical exams, while the patient examination provides additional data that can be collected through observations by a trained professional.
Tags: that patient, doctor office, initial assessment, medical history, patient examination, head-to-toe exam
