Article 3 of Law 41/2002 on Patient Autonomy defines the clinical history as the set of documents that contain data, assessments and information of any kind about the situation and clinical evolution of a patient throughout the care process. In this post we review the importance of clinical history in the world of medicine .
When a patient arrives for the consultation, their medical history gives us first-hand information about their health status and previous pathologies. Information that is very useful since it allows the doctor to do several things.
Importance of clinical history in health
Know previous ailments that explain the patient’s symptoms.
Guide the diagnosis. For example, if a child has residential phone numbers had several episodes of otitis and presents to the office with pain in the ear, by studying the child’s history the doctor may immediately suspect that there is a new episode of otitis.
Guide treatment. It is especially important to know possible allergies to drugs, as well as the existence of previous pathologies that would not recommend certain treatments. For example, when faced with an infection it is essential to know if the patient is allergic to penicillin.
Have an overview of the patient’s condition and its evolution over time.
In summary, the history facilitates health care, giving the doctor background information about the patient.
How to make a good medical history
Likewise, the clinical history has proven to be a very useful document for carrying out epidemiological or public health studies, allowing great advances in medicine. It can also be used in the field of teaching, although in all these cases the history will be anonymized that is, without data that would allow the patient to be identified.
On the other hand, medical history is not only important from a health point of view. It is also a legal medical document and as such serves as proof of the care received by the patient.
Currently there is no standard model for taking a medical history, although there are several elements that must appear for the history to be valid. Yes, we can give you some basic guidelines for preparing this document. You can find them here , along with BO Leads some practical examples.
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