What information is included in the patients biographical data?
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Chapter 2. Patient Assessment Show
The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013). Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The hospital will have a form with assessment questions similar to the ones listed in Checklist 16. Checklist 16: Health History Checklist
SexRecord male, female, hermaphrodite, transsexual, or unknown. In very rare instances, the sex cannot be determined. This information should be recorded. Age at DiagnosisThis refers to years of age at time of initial diagnosis for the reported cancer. Record age at last birthday; do not round to the next birthday. The age of children less than 1 year old should be recorded as 000. BirthdateRecord month, day, and year (including century) of patient's birth. If any of this information is unknown, record as NK (Not Known) or XX -- for instance, June, NK (or XX), 1925. Place of BirthRecord state for patients born in the U.S. For foreign-born, record country. Some registries and registry systems have developed a code to record city, state, and country. If your registry utilizes such a code system, record the code as determined from your geographic location code. The SEER Program uses GSA (Government Services Administration) codes for birthplace. Race / Ethnic GroupThere may be some problems in classifying individuals of mixed (multi-cultural) heritage--for instance, a person with a Japanese mother and an African-American father. Record all the details. Abbreviations on medical records can be misleading. Black is often specified as "B," "C," or "NW"-- black, colored, or non-white. However, "C" may also be used to specify Caucasian or Chinese; and Japanese patients may also be classified as "NW." Hence, when abstracting hospital records which utilize abbreviations, be sure you know exactly what the abbreviations mean. It will be of use to note a general rule in trying to distinguish between Chinese and Japanese names: usually, Chinese names have only one syllable and Japanese names have two or more syllables. Chinese names end in consonants; Japanese in vowels. Latin American and Puerto Rican are designations for ethnic groups, not races. In many sections of the country, ethnic groups are of particular interest, and you will need to identify them -- for example, Spanish surname or origin, such as Mexican, Puerto Rican, or Cuban. Marital StatusSelect the appropriate alternative: single, married, divorced, separated, widowed. Do not assume that a person specified as Miss should be classified as single. Often women who have been separated or divorced use their maiden names. A patient whose only marriage has been annulled should be classified as single. Patients having "common law" marriages should be classified as married. There may be some instances in which this information is unknown, particularly with the more frequent use of "Ms." OccupationRecord the patient's usual or primary occupation and the industry in which the patient is currently or was previously employed. Also, note a secondary occupation if one is listed in the medical record. This is particularly important for determining possible carcinogenic exposure, for example, people working with asbestos or in the manufacture of polyvinyl chloride. Social HistoryRecord information on use of, or contact with, carcinogenic agents, such as history of smoking, drug usage, and drinking. Many also record the use of birth control pills or any other information which your Committee on Cancer requests. Medical History
Admission DateRecord the date the patient was first admitted to your hospital for diagnosis and/or treatment of his or her malignancy. The patient may be readmitted many times for the same primary. Record only the date of the first admission. Sometimes the patient may be seen and treated only in an outpatient clinic or in the radiology department. For such cases, record the date the patient first appeared at the outpatient clinic or radiology department for diagnosis and/or treatment of this malignancy. Diagnosis DateRecord the first diagnosis of this cancer by a recognized medical practitioner. This may be a clinical diagnosis and may not ever be confirmed histologically. When the biopsy is histologically confirmed, the date of diagnosis is the date of the first clinical diagnosis and not the date of histologic confirmation. Discharge DateRecord the date the patient was discharged from the hospital following the first admission for this malignancy. For patient seen only as outpatients, leave blank. Which of the following is an example of biographical data?Examples of biodata include name, age, maiden name, contact information, date of birth, residential address, genotype, race, skills, allergies, hobbies emergency contact, and blood group, to mention a few.
Which is not included in the biographic data?Biographic data does not provide a history of an individual, only information related to a unique case. Biographic data includes, but is not limited to, name, date of birth, nationality, and other personal descriptive data.
What information could be found in a patients demographics?Patient demographics include identifying information such as name, date of birth and address, along with insurance information. Patient demographics streamline the medical billing process, improve healthcare quality, enhance communication and bolster cultural competency.
What is biographical and demographic information?Bio-demographic information includes data such as: legal name, date of birth, address, phone number, ethnicity, gender, social security number, citizenship status.
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