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Medical Record
What should I know about you?

The medical record shall include, at a minimum, the following items (if applicable):
Assessment of patient.
Address
Acquired harms
    Do you feel you have been harmed?
    How have you been harmed?
    Has the patient been harmed?
    Have you been harmed?
    What are the various acquired harms?
    Here are further guidelines.
Activities of everyday living
Anthropometric measurements
Annual health assessment
Annual health assessment of a child
Annual Physical Examinations
Assets
Abilities/skills
A medical doctor needs a doctor (physician) for himself.
Birth History
Birth Defects
    Does the patient have any birth defects?
    Do you have any birth defects?
    What are some of the various birth defects?

    Here are further guidelines.
Complaint
    When did it start?
    How long has it been going on?
    Does anything make it better or worse?
    Is anything else bothering you?
    Have you ever experienced anything like this before?
    Complaint
    Problem
Criminal Screening
Comprehensive Health Assessment (Introducing Two-Part Analysis Questions)
Comprehensive Health Assessment (Introducing Two-Part Analysis Questions)
Communications
Doctor Consultation
Duties
Detention
Death Investigation
Education
Evaluation, Diagnosis, Treatment by Other Doctors
Emotions
Emergency
    Medical emergency
    Detention
    Emergencies as per medical specialties
    On-the-spot emergency medical diagnosis and treatment.
    On the way to the hospital treatment.
    Emergency room treatment.
    In-hospital treatment.
    Critical care treatment.
    Outpatient follow-up treatment.
    Online treatment.
Follow-up medical consultation
Family History
Female Medical History
Food
Friends
Functional Assessment
Feelings List
Needs List
Health Calculators
Habits
Hospitalization records
How to Choose a Doctor
Harmful females
Identity Card
Internet health care resource for the resident.
Language
Laboratory Tests
Last updated
Legal case evaluation.
Life stressors screening
Medical emergency
Medico legal case
Medical history
Mental status examination(Psychiatric Consultation Service)
Medical record correction
Medical doctor to medical doctor communication about patient
Medication
Medical Doctor
Medical emergency resource for the resident.
Mobility
Functional Assessment
New Patient Consultation
New Patient
Outpatient medical services record
Patient Profile
Profile
Past medical history
Primary health care physician for the resident.
Physical fitness questions
Patient to medical doctor communication
Patient been referred to you by others
Profile People
Problem/Complaint
Patient Education
Patient been referred by you to others
Patient to medical doctor communication
Past History
Patient Education
Profile of patient
    Profile of patient
    Patient Satisfaction
    Photograph
    Health Care Opinion Survey
    Health Care Well-Being
Personality questions
Physical examination
Profession
Professional Boundaries - Faculty & Staff
Relatives
Relationships
Relationship Counseling
Religious Preference
Referrals
Screening of harms
Stress
Screening
Skills
Surgery
Surgical Documentation
Survival Needs
Sexual Health
School-based screening
    Hearing and vision deficiencies
    Dental problems
    Posture issues
Sleep History Questions
    Do you have any difficulty falling asleep?
    Are you having difficulty sleeping throughout the night?

    Here are further guidelines.
Travel history
Traits of Human Consciousness
Talking with Your Doctor
Vitals

Consciousness is extremely essential in reaching a correct diagnosis and treatment.
Consciousness, pulse, blood pressure, respiratory rate, temperature.
Female Medical History
Patient Information
    What is your name?
    ________________________

    First Name:______________

    Last Name:______________

    What is your real, birth name?
    ______________________________
    Where and when were you born?
    ______________________________
    How old are you?
    ______________________________
    What is your Email address?
    ______________________________
    What is your mailing address?
    ______________________________
    What has been your mailing address from the time of your birth until now?
    ______________________________
    What language do you speak?
    ______________________________
    What is your height?
    ______________________________
    What is your weight?
    ______________________________
    What is the color of your skin?
    ______________________________
    What is the color of your hair?
    ______________________________
Lifestyle Information
    What is your normal day like?
    ______________________________
    Do you smoke?
    ______________________________
    Do you use alcohol?
    ______________________________
    Do you abuse any drugs?
    ______________________________
Contraceptive history
Children
Diet
Ethics
Emergency
    What medical history and physical examination is required in a pregnancy emergency?
    Here are further guidelines.
    What are human pregnancy medical emergencies?
    How should you do a quick assessment, diagnosis, and treatment of a person reported as a human pregnancy medical emergency?
Family History
Family-Centered Maternity Care-Pregnancy
Female Medical History
Human Pregnancy
    What should you know about human pregnancy?
    Here are further guidelines.
Menstrual history
Menstruation
New Patient Consultation
Obstetric history
Obstetrics & Gynecology History
Prenatal care Personality questions
Previous Pregnancies
Planning for pregnancy (Parenting Advice)
Problem/Complaint
    Do you have any problem, complaint, or issues as of today?
    History of Present Pregnancy
    History of Present Illness
Past medical history
Physician Details
Pregnancy (Initial profile)
1st Trimester
2nd Trimester
3rd Trimester
Provisional Diagnosis
Pets
    Do you have any domestic pets?
    Domestic pets, Dogs, Cats, Birds, Farm animals.
Sexual Health (Health & Sex.)
Children
Annual health assessment of children.
Acquired harms
Birth History
Birth Defects
Pediatrics.
Hospital Patient
Hospital Patient
Hospital
Hospital Medical Record
Cardiology
Psychiatry
Gastroenterology
Disability Specialist
Geriatrics
Medical record

Medical history
Medical law
Patient Profile
Aisha (mummy)
Who should maintain electronic health records?
The state department of health.
A medical doctor and his or her team.

How often should electronic health records be updated?
Electronic health record should be updated as soon as new findings are available.

What is the medical history of a patient?
The medical history of a patient is a longitudinal record of what has happened to the patient since birth.

What is the difference between medical history, medical record, electronic health record, and emergency medical record?
If you have a new patient, you have to get his or her medical history since birth. This is medical history.

Once this medical history is maintained in any format (paper, electronic), this becomes a medical record.

A medical record preserved via the Internet is an electronic health record.

All facts gathered during a medical emergency become an emergency medical record.

Did you know that 90% of doctor visits are for stress related symptoms?

How many human medical conditions are there?
There are more than 7,000 human medical conditions.

Why should you call them medical conditions instead of diseases?
Diseases usually indicate an underlying pathology.
Not all medical conditions have an underlying pathology.

How many medical conditions are caused by stress?
More than 100 medical conditions are the result of stress. These are the most common medical conditions.

Why is there a need to elaborate on life stressors?
Life stressors are most common cause of various common medical conditions.

Medical Doctor
Is this complaint about your health or someone else’s?
What best describes the complaint about your health?


New Patient Consultation
http://www.qureshiuniversity.com/medicalhistory.html

Medical emergency
http://www.qureshiuniversity.com/medicalemergency.html

What are the sources of medical history?
Patient.
Family.
Patient not responding to medical history questions.
Community member.
Police officer.
Referral from medical doctor.
Other.

What are various emergency guidelines for the public?
http://www.qureshiuniversity.com/emergencyguidelinesforthepublic.html

Who has the medical record of the patient?
What should a medical record of a patient look like?
Who should update the medical records?
How is a medical record maintained?

Electronic medical record.
Medical records in paper format.
Emergency medical record.

What should a medical record contain?
What should an emergency medical record contain?
What are the scenarios in which medical records can be obtained?

Routine requests for medical records.
Legal proceedings or in response to a request to release patient medical records.
Court.
Updating the medical records.

Workers in Health Care

What are various workers in health care?

http://www.qureshiuniversity.com/workersinhumanhealthcare.html
How should you communicate with your medical doctor?
Who is your primary care physician, medical emergency resource, Internet health care resource?

This should be communicated to the residents in the state.
Internet health care resource for the resident.
Primary health care physician for the resident.
Medical emergency resource for the resident.
What should be the priority of the health care system?
GYN HISTORY
What are various methods to list a medical record?

How should every state department of health maintain medical records of all residents?
In alphabetical order.
Based on specific pattern or institution.

A medical record in alphabetical order is preferable.
What should I know about you?
Address
Activities of everyday living
Annual health assessment
Assets
Abilities/skills
Complaint/problem
Communications
Duties
Detention
Education
Hospitalization
Language
Photograph
Profession
Referrals
Survival Needs
Stress
Travel history

What is your name?
_________________________

What is your date of birth?
_________________________

Where and when were you born?
_________________________

What is your gender?
_________________________

Address

What is your mailing address?

________________________

________________________

________________________

________________________

Where are you located now?

________________________

What was your mailing address from birth until now?
_________________________

_________________________

_________________________

_________________________

Where do you live now?
_________________________

How long have you lived at this address?
_________________________

What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency?
_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

How long do you plan to live at this address?
_________________________


Activities of everyday living

What is your normal day like?
_________________________

What do you normally enjoy doing?
_________________________


Annual health assessment

When was your last annual health assessment done?
_________________________

Who did your last annual health assessment?
_________________________

What were the findings?
_________________________

What were the recommendations?
_________________________

Did the recommendations help?
_________________________

Was it an annual health assessment or evaluation of a new problem?
_________________________

When did you last see a medical doctor?
_________________________

Did you see a medical doctor for an annual health assessment or a new problem?
_________________________

What seemed to be the problem?
_________________________

What was the diagnosis and treatment?
_________________________

What is the name and contact information of the medical doctor who gave you this diagnosis and treatment?
_________________________

Assets

What are your assets?
_________________________

Abilities/skills

What are your abilities and skills?
_________________________



Complaint/problem

Do you have any complaint/problem relevant to human health care today?
_________________________

If you have any complaint/problem relevant to human health care today, what are the details?
_________________________

How are you feeling today?
_________________________

Do you have any problems today?
_________________________

What seems to be the problem?
_________________________

_________________________

_________________________

_________________________

_________________________

Communications

What is the best method to communicate with you?
E-mail.
Fax.
Telephone call.
Postal mail.
Communication through media.
_________________________


Duties

Do you have any duties?
_________________________

Who assigned you these duties?
_________________________

Detention

Were you ever detained or jailed?
_________________________

How many times and how long were you detained or jailed, and what were the reasons?
_________________________

Do you think your detention and/or being put in jail was justified?
_________________________

What concept of law is applicable to this scenario?
_________________________

Education

How would you rank you education level?
_________________________

Is you educational level at primary school, middle school, high school, associate’s degree, bachelor’s, master’s, or doctoral degree?
_________________________

What subjects have you studied?
_________________________

What profession have you studied?
_________________________

What are your abilities?
_________________________

What services can you provide?
_________________________

Have you designed or developed any products and services?
_________________________

What are the issues?
_________________________

Did your parents/guardians and school raise you with liberal values, religious values, or some other values?
_________________________

How were you raised?
_________________________

What best describes your English language abilities?
_________________________

What details should I know about you now that might later create problems for me, you, and others?
_________________________

What are your goals or plans?

_________________________

Hospitalization

When was the last time you were hospitalized?
_________________________

What were the reasons for hospitalization?
_________________________

How long did the hospitalization last?
_________________________

Do you think the hospitalization was justified?
_________________________

Language

Do you understand, speak, read, and write the English language?
_________________________

What languages can you understand, speak, read, and write?
_________________________

Photograph

Where is your recent photograph?
_________________________

Where and when was this photograph taken?
_________________________

Where is your state ID with a photograph?
_________________________


Profession

What profession do you identify with?
_________________________

Referrals

Did anyone refer you to this resource?
_________________________

Did the referring resource provide any referring document?
_________________________

Who referred you?
_________________________

What are the details of referral?
_________________________


Survival Needs

Has the state provided you enough survival needs?
_________________________


Stress

Do you feel stressed now?
_________________________

What are normal complaints, symptoms, and signs of stress?
_________________________

Do you have any of the complaints, symptoms, and signs of stress listed?
_________________________

What do you think is the cause of your stress?
_________________________

Did you know that 90% of doctor visits are for stress related symptoms?
_________________________

What do you know about stress?
_________________________

Write down any symptoms you're having, including any that may seem unrelated to the reason for which you scheduled the consultation. Note when your symptoms bother you most — for example, if your symptoms tend to get worse at certain times of the day, during certain seasons, or when you're exposed to cold air, pollen or other triggers.

_________________________

_________________________

_________________________

Write down key personal information, including any major stresses or recent life changes.
_________________________

_________________________

Make a list of all medications, vitamins and supplements that you're taking.Take a family member or friend along, if possible. Sometimes it can be difficult to recall all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

_________________________

Write down questions to ask your doctor.
_________________________

What are the sources of medical history?
_________________________

Patient.
Family.
Patient not responding to medical history questions.
Community member.
Police officer.
Referral from medical doctor.
Other.

Where is the patient now?
_________________________

Travel history

Where have you travelled up to now in North America, Asia, Africa, Australia, Latin America, or Islands even for one day?
_________________________

These are basic questions.
There are many more.