Collection and Documentation of Health History

Powerful Essays
Collection and Documentation of Health History

Purpose of Health record

Health history or health record is a systematically created document which stores the complete history of the diseases and physical conditions of the patient. This document gives a chance to the physicians to understand the complete background of patient’s physical health and helps them to plan their further strategy for the treatment of the patient.

This document also provides an opportunity to educate medical students and to provide data for medical research (Makoul, 2003). Health history is the first and foremost part of any medical examination. This data helps the physician to understand the physiological, psychological and sociological problems of the patient and gives a clue to the physicians for their treatment (Desmond & Copeland, 2000).

Components of Effective Health History

The complete medical history, with slight variations, may consists of:

• Biographical data: it consists of information regarding patient’s personal life. It helps to determine the cultural background of the patient through which the physician can identify any specific need and belief that may affect the health of the patient. The information regarding patient’s education and status helps to determine his strengths and weaknesses and the factors which may affect his / her health. For example if a patient holds a high profile position, maybe the stress of the job is the major cause of the disease etc.

• Present disease: this part describes the current health problem of the patient and why he or she wants to seek the health care

• History of present disease: this part provides the detail of the current health problem like how the problem started, what are the symptoms, ...

... middle of paper ...

...ike to be touched by strangers etc. (Berlin & Fowkes, 1983)


The basic purpose of health care is caring the human being. Health care professionals perform an extremely difficult job. They are the one who provide the physical care to the patients as well as their families. They support them psychologically, socially, mentally and spiritually. Their role is a combination of a caregiver, a teacher and an advocate of the patient.

The relationship between health care professional and patient starts while recoding the health history of the patient. This is the initial and one of the most important parts of providing the health care services to the patient. There are several strategies which can be adopted by the health professional to get the most information out of the patient which helps the physicians to plan their treatment strategies of the patient.
Get Access