Ethical Use of History or Physical Examination Data

Ethical Use of History or Physical Examination Data

A particularly important guideline for use whenever information is elicited from a person through the health history or physical examination is that the person has the right to know why the in-formation is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used (Fuller & Schaller-Ayers, 2000). It is also important that the individual be aware that the decision to participate is voluntary. A private setting for the history interview and physical examination promotes trust and encourages open, honest communication. After the history collection and examination, the nurse selectively records the data pertinent to the patient’s health status. This writ-ten record of the patient’s history and physical examination find-ings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. This protects confidentiality and promotes professional conduct.