A Medical History, Medical Record, or Health Record is an accumulation of all the information that has been compiled togethor from all the visits a patient has made to healthcare providers. It has all the diseases, illnesses, and growths the patient has had.
This is general information on the patient such as Name, address, phone number, ext.
An accumulation of all surgeries performed on the patient. The record will have dates of the operations and also a report on what the surgeon did, the outcome, and anythings else of note during the operation.
The patient's current and all previous medications will be contained in a summary. Any medical allergies will also be noted.
In the family history the health status of immediate family members will be listed. Also, if it applies, the causes of death will be listed. Diseases that are common in the family will be listed. Some reports also have a pedigree chart in them. The family histroy part of the record is valuable in predicting outcomes for the patient.
The social history is the patiients lifestyle. It has the patients career, schooling, religious practices, and relationships. This information allows the physician to know what community the patient is in, and what to expect in a major illness. It also can give clues to the cause of an illness.
There are many lifestyle habits that affect health. These include alcohol intake, tobacco, recreational drug use, exercise, and diet. Sexual preferences and sexual habits may also be included. These details are ofter part of the social history.
The patients vaccination history. All blood tests proving of immunity are included.
Comparative growth charts are included for children and teenagers as they compare to others of their age. This is for the physician to follow the child's growth over time. Diseases and social stresses can affect growth. Charting growth can provide clues to illnesses not otherwise detected. Allong with growth the child's behavior is documented as it compares to other children. This would include when the child first started walking, talking, etc.
There are many aspects of a patient that are documented in their medical history. So far these are categories that physicians will look for and record to be able to provide better health care. Next are the ways that physicains get this information from patrients.
physicians will have patients fill out questionairs to get basic information such as,
* Name, age, height, weight.
* The health concern and its history.
* Medical history. Past illnesses, surgeries, diabetes, ext.
* Family history of illnesses.
* Childhood history of health.
* Life style, occupation, drug use(perscriptions, tobacco, alcohol, others)
* Allergies.
This is the primary way for a patients medical history to form. Each encounter is recorded and documented by a summation of the patient by a physicain, physicain assistant, or a nurse practitioner. When a patient is admitted to the hospital an extensive form detailing almost all of the patients prior health and health care. Routine visits and checkups do not require a form as extensive. This is a problem-oriented medical record for the reason the patient came in.
All encounters will have parts of the following aspects:
The reason the patient has gone in to see the doctor. This is information on the type of problem and how long it has been going on.
A detailed description of the symptoms the patient is experiencing which made the patient seek medical attention.
All observations are recorded in a physical examination of the patient. Vital signs and an examination of different organ systems are observed and recorded, expecially ones that may directly be linked to and responsible for the symptoms that the patient is experiencing.
This is a written summary of what the most likely causes of the patient's symptoms are. The plan diagnosis and advised treatment, or expected actions to addess the symptoms.
Medical providers include written orders in the medical record. These are the detailed instructions that are given to members of the health care team by the primary providers.
When a patient becomes hospitalized daily updates are put into the medical record to document clinical changes and any new information on the patient. These entries are kept in chronological order to document the sequence of events leading to the patients current state of health.
The results of any testing that is done on the patient. For example blood test, X-rays, pathology, or any specialized testing.
There are other items of information that are valuable to keep in the medical record. Images of the patient, informed consent forms, outputs from medical devices such as pacemakers, and numerous other important pieces of information from the record depending on the patient and their illnesses and treatments.