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Components of good history taking include: 1. Chief Complaint -Symptom(s) For what has the patient come to the clinic? Sometimes the patient may identify two or more conditions that they may wish to address. When this happens, we use the checklist in detail for each of the complaints. -Duration .How long has this condition lasted for? What is its onset? What it is severity/ character? -Location and Radiation -Aggravating and relieving factors Any home-based treatment to understand the aggravating and relieving factorscourse of illness. 2. Past History of similar or related complaint 3. Family History eg. High BP in family members 4. Personal/ Social History eg. habits such as alcohol, smoking, etc and drug allergies |
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Here’s an example of a CHW taking history using the Intelehealth app’s Hx Guide and conducting a physical exam [link]. This would guide the doctor’s diagnostic ability [link] to provide evidence-based care.
Pic: CHW with her tools (Backpack kit) explaining about the process, taking consent and explaning explaining about data privacy of the data to be gathered in the session.
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Pic : CHW writing down the patient particulars and taking down the history
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