Deviation in the Standard of Care When Obtaining Medical History Resulting in Exacerbation of Illness

Evaluate breaches in the standard of care when determining whether or not there has been a Deviation in the Standard of Care When Obtaining Medical History Resulting in Exacerbation of Illness

Answer the following questions to find out if the standard of care was followed for your case.

  • Did the clinician obtain and document a history of the presenting illness?
    Yes
    No
    Answer unknown
    Why is this important?
    The clinician needs to investigate specific facts, symptoms, and information about the presenting illness. The information needs to be documented in the medical record.
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  • Had patient ever experienced similar symptoms in the past? Why is this important?
    Answer this question
    Any occurrence of previous clinical symptoms needs to be investigated and documented.
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  • Did the clinician document any other associated symptoms? Why is this important?
    Answer this question
    The presence of any associated symptoms as well as the symptoms of concern must be elicited from patient and documented in the medical record.
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  • Did the clinician obtain and document the names of any and all other physicians involved in the patient's care? Why is this important?
    Answer this question
    The medical history should include all the clinicians involved in treatment of the patient.
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  • Was the patient's vaccination history obtained and recorded? Why is this important?
    Answer this question
    Primary Care physicians need to review patients' vaccination history periodically, and make advisements regarding seasonal or age-appropriate vaccines when indicated.
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  • Which of the following were not elicited as part of patient's allergy history? (Choose all that apply) Why is this important?
    Answer this question
    All previous and present allergic reactions related to drugs, food and the environmentmust be elicited and documented by the clinician as a part of allergy history.
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  • Did the clinician document history regarding the current and previous medications from the patient? Why is this important?
    Answer this question
    A list of current medications includes prescriptions, over-the-counter medications, vitamins, and herbal preparations.
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  • Did the clinician document the patient's previous hospitalizations? Why is this important?
    Answer this question
    Patients who are intermittently exposed to the health care environment may become introduced tohealth care–associated pathogens.
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  • Did the clinician document whether the patient had ever had a blood transfusion? Why is this important?
    Answer this question
    Transfusion-associated risks of a noninfectious nature include hemolytic and non-hemolytic transfusion reactions, fluid overload, graft versus host disease, electrolyte and acid-base imbalances, iron overload, increased susceptibility to oxidant damage, exposure to plasticizers, hemolysis with T-antigen activation of red blood cells, post-transfusion purpura, acute lung injury, immunosuppression, and alloimmunization.
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  • Was a detailed review of symptoms documented? Why is this important?
    Answer this question
    The review of systems, the structural assessment of each ofall the major organ systems, elicits signs and symptoms not covered in the history of the present illness.
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  • Did the clinician review and document the patient's co-morbidities? Why is this important?
    Answer this question
    A number of medical and social co-morbidities, including obesity, nutritional insufficiency, diabetes mellitus, urinary tract infections, cancer, hypertension, and smoking, have been associated with an increased incidence of other medical conditions.
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  • Did the clinician obtain a comprehensive list of past medical conditions and previous treatment modalities? Why is this important?
    Answer this question
    The past medical history shouldinclude past and current medical and surgical conditions, past and current use of medications (including vitamins, herbs, and nontraditional remedies).
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  • Was a history of all previous surgical and non-surgical procedures obtained? Why is this important?
    Answer this question
    It is necessary for the clinician to review and document all past surgical and non-surgical procedures.
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  • Was a detailed family history obtained and documented? Why is this important?
    Answer this question
    A thorough family medical history is essential to obtaining a comprehensive health evaluation.
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  • For the pediatric patient, was a developmental history obtained? Why is this important?
    Answer this question
    Child maltreatment is a pervasive worldwide problem with both short- and long-term physical and mental health and developmental consequences.
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  • Did the clinician investigate and document a social history? Why is this important?
    Answer this question
    The social history of the patient should comprise his style and any possible risk factors leading to a disease condition. The tobacco history should include the use of snuff, chewing tobacco, and cigar and cigarette smoking. Alcohol use should be determined quantitatively and by the effect that it has had on the patient’s life. Past or present use of illicit substances, prescription of pain medications or sedatives, and intravenous drugs should be assessed.Information on patient’s socioeconomic status, insurance, patient’s ability to afford or obtain medications and past or current barriers to health care should be documented as part of history taking.
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  • Did the clinician investigate the possibility of any unhealthy habits or behaviors? Why is this important?
    Answer this question
    While taking a history of chronic illnesses, physicians should ask about self-monitoring, adherence with medications, and self-care practices.
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  • Did the clinician obtain the sexual history? Why is this important?
    Answer this question
    It is necessary to obtain and document a sexual history of the patient.
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  • Did the clinician obtain and document a reproductive history? Why is this important?
    Answer this question
    It is recommended that a reproductive history be obtained and documented from the patient.
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