Clinical History
Clinical history is essential for medical care. This is because keeping information about the patient’s health history stored can be very important when working with hypotheses for diagnoses and recommending treatments.
So, when analyzing the clinical timeline along with the symptoms presented, it is possible to work more assertively and reliably in favor of the patient’s health.
Continue reading this text to understand the concept of clinical history and its importance for medical practice.
More about clinical history
The medical history is a list of all data and information about a person’s health. Therefore, according to the scientific article “ Agony of the clinical history and its consequences for medical education ”, the clinical history is an indispensable tool for the good training of health professionals.
According to the content published in the Revista Brasileira de Educação Médica, “the clinical history is not a “format” or a formality, but rather a successive occurrence of the patient’s complaints and what the doctor actually did for his benefit”. In practice, this tool consists of combining information collected in the anamnesis and physical examination.
From the history of different stages of life, the doctor has a means of studying the health of the patient. This set of data is very rich and offers ideals that will guide medical research in search of a diagnosis. In addition, the clinical history also gathers information that allows you to draw a timeline with all the diseases and problems that a particular patient has faced.
Thus, the clinical history is a kind of report that brings together, in one place, current and past illnesses, in addition to illnesses present in the family , test results, anamnesis sheets, among others.
What is the importance of following the clinical history?
The clinical history, above all, is a document that serves as a guide for the health professional. With it, the doctor can identify several factors about the patient’s health condition . In this way, it is possible to understand some symptoms and link them to possible diagnoses, as well as predict genetic pathologies or possible aggravations.
For example, many diseases are asymptomatic and therefore more challenging at the time of diagnosis. However, many of them can be considered if the doctor evaluates the patient’s clinical history and analyzes his past illnesses.
In addition, before prescribing any medication or treatment, the physician needs to have information on what has already been done, what were the results obtained and what worked best in each situation. This is especially true if the patient has any allergies or restrictions. The clinical history sheet, therefore, holds precious and relevant information for good medical care.
What items are analyzed in the clinical history?
The clinical history document is filled with valuable information for the physician. Initially, it presents information such as full name, date of birth, gender, address, telephone and other contact options. But in addition to patient identification data, the clinical history also contains:
1 – Physical information
The body can say a lot about a patient’s health. Among the information that needs to be evaluated, since they are related to specific diseases, are: height, weight, color, blood type , continuous use of medication , addictions, physical activity, sedentary lifestyle, among others.
2 – Recent history
In this step, more health-oriented information and recent patient data are filled in and stored. This information is valuable so that the doctor can consider possible complications, side effects resulting from some medication or newly prescribed treatment, for example.
In addition, the doctor will organizational culture. Only with this data will HR be able to check if the patient was well, if he had or is going through an illness, if he was recently hospitalized or had surgery recently. Remembering that the clinical history document will always have reliable and reliable data.
3 – Chronic diseases
The medical history should contain all of the patient’s chronic illnesses. They are slowly progressive diseases that can accompany us for most of our lives. These pathologies are aggravating factors and have specific symptoms. In addition, some medicines and treatments are not indicated for patients with this type of disease.
4 – Family history
In addition to the patient’s own history, information from the family’s health history should be analyzed in order to assess whether there is the possibility of any hereditary and genetic disease. This information must be medical knowledge.
5 – Medication history
It is also important to pay attention to the medications for continuous use or those that were used to treat a certain reported disease. This avoids prescribing medications that may cut or reduce each other’s effect.
6 – Other information
It is important to understand that each patient is unique and may have clinical particularities. Thus, a clinical history will never completely follow the same pattern. So don’t just stick to the basic information. Evaluate everything that the patient reveals at the time of the anamnesis.
How can the patient help keep his medical history up to date?
Although it is the role of the doctor and the health institution to take care of and store the clinical history document, the patient will always be the protagonist of the updates. Therefore, guiding you on the importance of keeping data up to date is essential.
In each new consultation, the patient will organizational culture. Only with this data will HR be able to add information to his/her history and, in this way, optimize the doctor’s work. In addition, the health professional must reinforce to the patient that he has active responsibility for the correct care of his health condition, following the proposed treatments.
Technology can be a great ally in the process of monitoring clinical history. Using mobile applications on the smartphone , for example, it is much easier to update and forward relevant data to the doctor. These tools also help the patient to record information about appointments, exams, vaccines and other important data.
In the Zello Saúde application , you can gather the most diverse information and it has very efficient features to help you maintain your health. It unifies all your consultation history and medical exams. Try the app for free here:
