会计学WhatishistoryrecordImportanceofhistoryrecordHowtomakeagoodhistoryrecordHowtomakeagoodhistoryrecordBasicrequirementforthehistoryrecordA.Outlineofcaserecord3.Historyofpresentillness(HPI)Thehistoryofpresentillnessshouldbeawell-organized,sequentiallydevelopedelaborationofhischiefcomplaint(s)onitsvariouscharacteristics:①dateofonset,②characterofcomplaint,③modeofonset,courseandduration,④location,⑤relationshiptoothersymptoms,bodilyfunctionandactivities,⑥exacerbationandremissions,and⑦effectoftreatment.4.Pasthistory(PH)Itshouldincludeareviewofallpastillnesses,surgicalprocedures,andinjuries,andallergyhistory(medicine,food),whichareparticularlyrelatedtothepresentillness.5.Reviewofsystem(ROS)Thepurposeofsystemreviewistwofold:athoroughevaluationandadoublecheckpreventomissionofsignificantdatarelativetothepresentillness.Thereviewisacomprehensiveaccountofallcomplaintsreferabletoeachbodysystemprogressinginalogicalmannerfromtheheadtowardthefeet,includingrespiratorysystem,cardiovascularsystem,digestivesystem,Urinarysystem,hemopoieticsystem,endocrinesystem,nervoussystemandskeletalsystem.6.Personalhistory(socialandoccupationalhistory)Itincludespersonalhabits(smoking,alcoholdrinking),businesslife,sexlife,occupation(exposuretocertainirritatingagents),conditionofwork.7.MaritalhistoryItincludesdataconcerningthehealthofmate,sexualadjustment,thenumberofchildrenandtheirPhysicalstatus,andthegeneralsocialadjustmentwithinthefamily.8.Menstrualhistory(forfemalepatients)Ageofonset,intervalbetweenperiods,duration,amountandcharacterofflow,concomitantsymptoms,dateoflastmenstruation,ageofmenopause.9.Childbearing(reproductive)historyAgeanddateofpregnancy(ies)andchildbirth(s).Dateofartificialornaturalabortions,stillbirths,operativedelivery,puerperalfever.Methodoffamilyplanning,thepossiblefactorsofinfertility(alsoformalepatients).10.Familyhistory(FH)Thehealthstatusofthepatient’sfamily(mother,father,siblingsandchildren)andifdied,theageandcauseofdeathshouldberecorded,suchasdiabetes,hypertension,cancer,