Data from a medical record helps analyze a patient’s medical journey. It is a basic document when making a medical decision, which is why the data in a medical record must include all types of data about a patient’s health.
What is a medical history
The clinical history is a record of data that is extract from previous examinations carri out on the patient. This document must include the results of the examinations, treatments, diagnoses and any information that may be relevant for future examinations.
Any data that may be relevant to the patient’s health should be reflect in this report, which is normally structur in five blocks.
What information is reflected in a personal medical history
Subjective data provid by the patient: This is the information provid by the patient himself about his condition. Normally we refer to the data that the doctor collects by telephone list asking the patient himself by the term anamnesis.
Examination data: This is objective data extract from the patient’s examination. This information is fundamental and objective, since it is the doctor himself who extracts the information from the physical examination.
Diagnosis: Each diagnosis is reflect in a patient’s medical history. This section identifies the disease or pathological state located in the patient.
Data management of an online medical record
Prognosis: The doctor makes an approximation of what the patient’s evolution will be bas on the symptoms that the patient presents and the previous examination.
Treatment: Finally, it is necessary to reflect the treatment recommended to the patient. It is also important in this case to identify possible personal characteristics about the treatment, such as allergies to medications, etc.
Usually the clinical history is complet in an analogue way, therefore, there is a single copy that must be consult on the paper itself. Clinic Cloud has a clinical history module that you can customize to include all the medical information of your patients, in addition, The file is record in the cloud, therefore, any professional in your clinic will be able Frist Database to consult the data online immediately.
All the patient’s clinical information is protect and can be consult and modified in real time. You can consult each patient’s file at any time and work with preconfigured templates.