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Development of a computer-assisted method for the collection, organization, and use of patient health history
Abstract:
Screening a patient's general health prior to instituting physical therapy management is generally acknowledged as important. However, neither the specific content nor the optimal method of performing this part of patient examination has received much attention. One method that uses a computerized information management system to assemble relevant clinical literature and to guide the collection, organization, and use of patient health history data in clinical decision-making is described. The philosophy and rationale for performance of general health screenings by physical therapists, justification for the use of computers in the screening process, and the development and application of one type of computer-assisted health history screening system for physical therapy are presented.
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Related Concept Videos
Data Collection I
Data Collection II
Data Collection III
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
Purpose of Health Records II
Methods of Documentation II: POMR