Patient History -The Integral Part Of Medical Report

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PATIENT HISTORY
The Integral Part Of Medical Report
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• It is true Listen to your patient, and they tell
  you the diagnosis
• Modern medicine practices are ethically bound to
  documentation of the data generated during
  patients treatment. Documenting complete
  information of the illness and treatment has
  generated enormous medical records. It can be
  history record/initial visit record, admission
  form, operative report, follow-up visit, therapy
  note, pharmacy note, discharge note or death
  report also. In all these reports, patients
  history is one of the essential element which is
  captured.

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Patient History

• This term can be defined as the past information
  of the patient which is medically important
  gathered mainly by asking specific questions to
  the patient or concerned people. This has proved
  to be the evidence based approach in differential
  diagnosis. History taking and documenting is an
  art. History is normally collected by nurse or
  the treating physician every time when the
  patient approaches the doctor for any new
  complaint mainly.

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• History of the patient is collected under various
  subheading, it has its own importance in the
  treating the illness
• History Of Present Illness Current complaints,
  events or incidences with relevant details are
  the part of history of present illness. The
  details include description of the injury,
  complaints, examination, finding, investigations
  and treatment rendered.
• Past Medical History It includes significant
  past diseases, illness, trauma, accidents or
  complications the patient has suffered in the
  past.
• Past Surgical History Past surgeries with
  complications if any are mentioned under this
  heading.

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continued

1. Family History This section includes medical
   history of the parents, siblings, children or
   blood relatives but never of spouse or in-laws.
2. Medicine/Drug History Current medications with
   dosage and medications taken in the past are
   listed under this heading.
3. Allergies Any allergies to drugs, food, animal,
   dust, pollen or seasonal are mentioned with
   effects seen on the patient.
4. Social History This includes patients habits
   like smoking, drinking, drug abuse, it also
   includes information on marital status,
   occupation, pets, habits and accommodation.

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continued

1. Systemic Assessment Under this subheading all
   the other complaints related to body systems are
   included.
2. Psychiatric History This is frequently lengthy
   and in depth history of patients emotional
   status.
3. Immunization History Immunizations from birth
   and yearly immunization dates are mentioned under
   this history.
4. Diagnostic Studies The review of the various
   diagnostic studies carried out for above
   mentioned problems are mentioned under this
   heading.

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• It is said that a good history is one which
  reveals the patients ideas, concerns and
  expectations as well as any accompanying
  diagnosis.
• Inhibition in collecting the good and relevant
  medical history could be due to inability of the
  patient to communicate, improper doctor-patient
  relationship, unwillingness of the patient to
  disclose certain information.

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Computer Assisted History Taking

• Computer technology started in 1960. It allows
  easy collection and portability of the medical
  data saving money and paper- known as electronic
  medical records.

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Advantages Of The Medical History In Medical Data
Processing

• Accurate medical history is an advantage for any
  care giver while treating the patient. There are
  many advantages of accurate history data in
  various other aspects related to medical field
• Insurance In settling the claim, medical history
  proves very helpful. Assessing the history from
  medical data decides the flow of the claim.
• Investigational Aspect Patient history in
  medical records plays and key role in
  investigational

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continued

1. Recruitments History of the patient is an
   integral part of the documents required for
   recruitment.
2. Pharmacogenomics to study genome in drug
   response patients history is a vital data that
   has been gattered. It is studied to better
   understand the biology behind diseases and drug
   response phenotypes.

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Conclusion

• ITCube BPO understands the widely spread
  importance of medical history. Handling all types
  of medical records and accurately correlating the
  medical history and summarizing it, which enables
  the review of those records easy and less time
  consuming. ITCube caters this services to various
  litigation firms and TPAs, which indeed helped
  them to focus more on the core business as we
  provide the very precise, accurate and handy
  summaries saving their time to review the
  documents.