1.

Summary of medical record

IMPORTANCE OF PROFICIENCY IN NAVIGATING THE PATIENT'S MEDICAL RECORD
Depending upon the individual patient's characteristics, the inpatient medical record can be
quite lengthy, especially when there are numerous comorbidities or complications that
require a long hospitalization. Similarly, the outpatient medical record can become extensive
when a patient has had numerous encounters with the practitioner over many years' time.
Developing familiarity with where to find vital pieces of information makes the development
of an assessment and plan more efficient and effective. The first step is understanding the
contents contained within each component of the medical record.
COMPONENTS OF A PATIENTS MEDICAL RECORD
The medical record can be dissected into five primary components, including themedical
history (often known as the history and physical, or H&P), laboratory and diagnostic test
results, the problem list, clinical notes, and treatment notes.
Medical History
The medical history, or H&P, includes the following components:
1. Patient demographics.
2. Chief complaint (CC).
3. History of present illness (HPI).
4. Past medical history (PMH).
5. Family history (FH).
6. Social history (SH).
7. Allergies.
8. Medication history.
9. Review of systems (ROS).
10. Physical examination (PE).

2. Briefly explains why descriptions of patient's dietary habits, exercise routine, and use
of caffeine as well as years of education, occupation, marital status, number of children,
sexual practices, military history.
a. Patient eating habits
If having a history of poor eating habits can affect the nutrition given to the body as
diet and obesity
b. Regular exercise
A patient's record of wrongful exercise such as excessive exercise can have a
negative effect especially on the heart
c. Caffeine usage
If a client has a history of excessive caffeine use, it can cause irregular heartbeat
d. education
The history of education is one of the content of a client's identity and education can
affect a client's health knowledge
e. occupation
Employment history includes the content of a client's identity and can tell if work is a
cause of illness
f. Marital status
The marital status history is included in the client's identity and can determine if the
marital status includes the spouse's risk factor
g. Number of children
 A large number of children can be affected by heart disease
h. Sexual practices
A sexual history can affect sample disease risk factors if one couple has HIV
i. Military history
If the patient has a military history, it can tell if the patient has been injured or injured
during the war
j. Current living conditions
Knowing how the patient lives today to know the cause of the illness