Nursing Essay Assignment
Working in a hospital and specifically in the ICU, patients that I encounter are not always able to give a complete health history. Strategies that I have used in the past to obtain pertinent medical information have been to look through the chart. Researching previous encounters with the patient gives an idea of health problems that the patient may have. When I encounter patients that have never been seen in our system, I reach out to the other hospital system in my community. Having only two hospital systems, that 85% of the clinics in town belong to, makes it a little easier with places to search for information.If the patient is from an ECF, reviewing the records sent with the patient is another option. If records were not sent, requesting the records would be another way of obtaining medical diagnoses and allergy information. Another avenue for obtaining information that can help with completing a health history would be to check with the local pharmacies for prescriptions that may be filled by the patient. If the patient is taking a beta blocker, for example, it could be safe to assume that the patient has hypertension or atrial fibrillation. If the patient is taking warfarin, it would be safe to assume that the patient has atrial fibrillation or has a history of DVT. Accurate date is key to an accurate conclusion and being skillful at obtaining an accurate medical history is key (Gilden, 2017).
Gilden, J. L. (2017). The most accurate autonomic function test: the medical history. Clinical Autonomic Research, (4). 209.
The response should include a reference list. Double-space, using Times New Roman 12 pnt font, one-inch margins, and APA style of writing and citations.