General

Example of medical history

When we enter a hospital and they perform some type of procedure that requires hospitalization or when we consult with a specialist, a medical record is opened within that room.

What is a medical history?

Also known as medical history, it is the set of documents that contain personal data expressed clearly and concisely; such as the data generated in each of the healthcare processes , those referring to the state of health, medical evolution and the care received with very specific information.

What is a patient’s medical history for?

As in hospitals and clinics there is a turnover of personnel, the medical history becomes essential for the doctors on duty to quickly understand the condition of a patient that they did not attend before. It also serves to comply with the correct treatment according to the disease or condition of the person.

What should a medical history have?

The clinical-care data vary according to each patient.

  • Patient identification data.
  • Background of interest.
  • Anamnesis and examination.
  • Data on the clinical course of the disease.
  • Medical orders.
  • Pharmacotherapy.
  • Planning of special care.
  • Constants and other necessary or strictly necessary basic data.
  • Interconsultation: request and report.
  • Information from complementary examinations.
  • Informed Consents.
  • Registration information.
  • Anesthesia information: pre, per and postoperative assessment.
  • Surgical information.
  • Urgent information.
  • Delivery information.
  • Pathological anatomy information.

Examples of medical history

The following are just excerpts from some medical records.

JMS

Age: 78 years

Gender: Female

Occupation: Homeowner

Forecast: Fonasa

Address: Lira 1035

CURRENT ANAMNESIS:

Around 9:00 p.m. yesterday, at home, he trips over the edge of the carpet, landing on his right hip. She is in pain, cannot get up on her own and is helped by her daughter by leaving her lying on her bed. The next day she is not able to get up as any attempt to mobilize her right limb causes pain, for which she requests an ambulance that takes her to the Emergency Service of the Clinical Hospital.

REMOTE ANAMNESIS:

Morbid history:

Doctors: Take atenolol 1 tablet a day

Does not report other history of disease

Allergies: Does not report

Surgical: Cholecystectomy 10 years ago.

Transfusions: Don’t know.

System review:

Respiratory: Bronchitis in winters.

Others: Nothing special

Habits: Does not smoke, does not drink

Relatives: She lives with her only daughter, does housework and goes shopping daily

Physical exam:

General:

General condition preserved

Supine position, can semi-sit in bed

Conscious, well oriented, adequate communication, distressed by her pain.

Unable to roam.

Pulse: 88 x min. Regular

Blood Pressure: 150/80

Temp. Axillary: 36.8

Weight: 65 Kgs. (Verbal data)

Breathing: 14 x min., Of conserved amplitude.

Skin and phanerios: preserved for their age.

Related Articles

Leave a Reply

Your email address will not be published.

Check Also
Close