临床病史采集

Priscilla Peart
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引用次数: 2

摘要

非医务人员经常被要求从他们的角色中获取患者的病史。其他领域不教医生这样做的技能,这可能导致收集所需知识的能力有限。系统的病史记录可以提高任何临床医生做出关键判断和临床决定以安全治疗患者的能力。获取临床病史的顺序已经为几代医生所确立,但通常不向更广泛的卫生网络传播。通过了解基础知识和结构将使非医学临床医生能够从患者那里获得简明的病史,以帮助进一步的诊断评估。
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Clinical history taking

Non-medical staff are often required from their role to take a medical history from patients. The skills to do this to the level of a doctor are not taught in other fields and can lead to a limited ability to collect the knowledge required. The systematic sequence of history taking can increase any clinician's ability to make critical judgements and clinical decisions to safely treat the patient. The sequence of taking a clinical history has been established for generations of doctors but not often communicated to the wider health network. By understanding the basics and the structure will enable a non-medical clinician to take a concise history from a patient to aid in further diagnostic assessments.

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