Workshop: A Comprehensive Medical History

By Dr. Emid Nuñez Conde

The patient history is presented in a way of a step by step workshop for this lesson.

Context:

To build domino medical history regarding some knowledge is required so we must create a class that details the steps for conducting a medical history.

Using an exercise of knowledge building processes, creating knowledge structure from the simplest to the most complex.

Especially explain the material to achieve compression that encourages build an analysis of the patient's history.

This must be done in such a way that it tells the patient's story in a logical, clear and complete fashion yet is neither cumbersome nor too long. It is a difficult skill to master and is made more complicated by the fact that different clinical situations demand different types of presentations.

Presentations 

Given during morning work rounds (the time when the medical team briefly visits with each patient to review their clinical course and determine the plan for the day), are not the same as those given at formal patient management conferences.

The first situation 

Requires a focused presentation, with emphasis placed on reviewing new facts and data (e.g. test results, vital signs, changes in clinical course, etc.) and outlining the care plan.

The Second example calls for a much more detailed discussion.

The Presenter, then, must take into account the "environmental" factors which determine the type of presentation that is required.

At the end of a series of steps leading to the production of history into a team that promotes quality while producing continuous product evaluation.

I think we can summarize in the 7 steps

1) Study materials to acquire prior knowledge.
2) File the case and the variables and possibilities for diagnosis and treatment.
3) Next, I would leave every one of them starts to lecture to his individual opinion as to the history.
4) Then do the story and discuss each work.
5) In the end it makes the work table to discuss their views.
6) I let them adjust their work in history.
7) Then you must give me the definitive history and fact.

It is important for the student of this era of medicine, nurses and all staff working with clinical history is taught to work with computers for electronic records.

I think universities should incorporate curricula electronic records, telemedicine and teleconsultation within the integral learning  process Metacognitive of the medical history.