Introduction to Reference Sources in the Health Sciences: an interview with Jo Anne Boorkman, Jeffrey T. Huber and

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Data Collection II

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family,...
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Introduction To Health Care Delivery System

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Overview of Biostatistics in Health Sciences

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Purpose of Health Records I01:11

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The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
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Data Collection I01:30

Data Collection I

Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of data...