At the time when a person comes for the first time to take control of their health or solve an episode of illness, a personal and unique document that all data related to health will appear, either in a hospital, in a primary care center or in a medical office.
If you do not know for sure what the medical history of a patient and why it is used for, read on to get all the information on this important and necessary file related to health.
What is the medical history of a patient
The medical history is an essential document to keep all the information related to the health of a patient and the services and care provided to the same one.
Definition of medical history
You can define the clinical history as a legal document of the medical branch that arises from contact between a patient and a health care professional, where all the relevant information about the patient’s health is collected, so that he can offer a correct and personalized attention.
In the group of health professionals who have access to this document of a patient are: doctors, nurses, physiotherapists, dentists, psychologists, podiatrists, surgeons, ophthalmologists, and professionals from any other medical specialty.
Models of clinical history
Currently, the most common is to find medical records in electronic form, but so far have not been computerized all the stories created before the digital age, so they are in physical paper format. In addition to this categorization, there are three models, namely:
- Chronological medical history. Traditionally used in hospitals.
- Medical history oriented by health problems. Used in primary care centers.
- Medical history made for the specific monitoring of a disease, in specialized units and specific questions.
What data is included in the medical record of a patient
The documents included in the medical history of a patient collect all information concerning medical and care processes of that person. In them, the names of professionals who have intervened and of the applied medication. In short, any transcendental information that offers a truthful and updated patient health knowledge.
The exact information in the file is:
- Clinical-statistical documentation on sheet
- Entry Authorization
- Emergency report
- History and physical examination
- Medical orders
- Interconsultation sheet
- Investigations reports
- Informed consent
- Anesthesia report
- Report of surgery or birth registration
- Pathology report
- Development and planning of nursing care
- Nursing therapeutic application
- Constant chart
- Clinical discharge report
What is the role of clinical history?
The main function of the medical history is to facilitate the work of health professionals who have to treat a patient, knowing first hand and immediately all information concerning their health.
Its functions include the possibility that the physician provides personalized patient care, learn and improve the successes and mistakes in past treatments, investigate some scientific branches from the information contained in the document, improve the quality of health of a patient, manage and administer medical services of health institutions, etc.
Legal data on medical history
- The physician or health professional who accesses the confidential information that appears in a medical history, must maintain, according to the law and the Code of Ethics of the profession, privacy and confidentiality of such data, keeping the confidentiality of any information disclosed.
- The patient has the right to written record of any medical procedure in his case history, which also must be identified with a unique and personal number.
- The patient can access this data whenever he wants, and to receive a copy of it upon request. In addition, you are entitled to confidentiality and privacy of your data, and is also a felony access to medical records without authorization.