A document through which the specialist analyzes the most outstanding points of the patient who visits his office. For example, the clinical history in a psychology appointment is the personalized report that the psychologist created based on the observations and data of the process carried out by the patient since he arrived at the appointment.
There are some fundamental data for taking a clinical history. One of the most important data is the date of the visit in the consultation. In this way, the data noted in the session are contextualized within a deadline.
How to make a medical history
A specialist who offers assistance deals with very different cases. For this reason, each patient’s clinical history is completely individual and personalized. Thus, to carry out this customization, each clinical history must be accompanied by the name and surname of each patient.
At the beginning of the consultation, the clinical history must contain the reason for the visit. This history is a very important work tool for professionals working in the health field. For example, the family doctor also uses this means to classify each patient’s updated health information . In other words, this document contains the history of each protagonist, the assistance processes experienced so far. It is also possible to look at certain data as an allergy problem.
The recommended support for taking the clinical history is technological
The doctor also has a responsibility to protect patients’ personal data. This clinical history is very important when a particular case requires the work of a team of physicians from different specialties.
The clinical history must be signed, with the corresponding date and the collaboration of different specialists. This history must contain objective data such as diagnoses, treatments and the processes experienced by the patient. However, the doctor can make possible subjective assessments to give more value.
Clinical history of an operation
The clinical history indicates treatments, recommended care and patient evolution . One of the items in the clinical history related to the surgery details, for example, the type of anesthesia used, how the surgery was developed, the start and end time of the operation, and the identification of the professionals who participated in it.
Why is medical history important? Because the life of a human being is very long and its health characteristics can evolve. Without a doubt , when a data information system is not used to collect the most important points of the protagonist, this information is forgotten.