The clinical record is a legal and health document, where patient information is collected from basic personal information to the medical review. Following are some examples of clinical history and its characteristics.
What is a clinical history?
It is a medical and legal document, where the health professional reviews the most relevant data of a patient.
Within the data that is reviewed in the medical history , there are name and surname, identity document, sex, age, race, profession, occupation and clinical review.
Added to this, the medical file collects detailed and described information about the conditions presented by the patient and the diagnostic impression.
Subsequently, the analyzes and results of clinical examinations such as laboratory, images and other samples can be reported, until reaching the treatment.
Starting from the definition of the medical record , we will take an in-depth look at some examples of medical records in the five main areas of medicine.
Clinical history examples
1. History in general medicine
General medicine is responsible for addressing patients (regardless of whether they are children, adults or the elderly) from primary to secondary care.
In this clinical record model, personal data, address, reason for consultation or admission, own and family history, history of the current disease and positive findings are taken.
In the positive findings section, reference is made to those collected in the physical examination and interrogation ( anamnesis ), in addition to diagnostic tests.
On the other hand, it is essential to make a diagnostic impression and conclude with the behavior to follow in the treatment and the definitive diagnosis.
This model or format is the main one when approaching a patient in a general or family medicine office.
2. Pediatric history
Pediatrics is the medical discipline that is responsible for treating children from birth to adolescence (18 years in some countries).
For its part, it is based on diagnosing and treating diseases that affect this age group and there is another branch where healthy children are examined, called ‘ childcare’ .
Regardless of the area (pediatrics or childcare), the representative is questioned and information of interest to the parents and the child is collected.
Likewise, it specifies if there was prenatal control before the birth of the pediatric patient, eruptive diseases of childhood and previous operations.
For its part, it details the psychomotor development in the child, depending on the age at which it is, if it is a newborn, infant (younger or older), preschool, school or adolescent.
In this same way, it follows a similar pattern to the other clinical histories, only emphasizing the maneuvers performed in pediatrics.
3. Obstetric history
As for obstetrics , it is the medical branch that is responsible for ensuring maternal-fetal health until the birth of the baby.
In turn, this area may be related to gynecology , which establishes the main guidelines in women’s reproductive and genital health.
Regarding the medical history in obstetrics , extremely relevant data is collected, such as the patient’s personal information, genital and sexual development.
On the other hand, it emphasizes the main conditions prior to pregnancy and the history of pregnancy or losses (abortion), added to contraceptive methods.
It should be noted that the obstetric clinical record details the procedure to be performed at the time of delivery, whether it is by cesarean or vaginal section.
In the same way, it delves into the nutritional pattern of the future mother, in addition to the positive findings in the questioning and medical examination.
4. Surgical clinical history
Surgery is the medical branch that is in charge of studying the main diseases that affect an organ and which needs revision and treatment in a surgical procedure.
On the other hand, it is similar to the medical history in internal medicine , but with several exceptions, such as the methods that are to be used or used in a procedure.
In turn, structure in an organized way, the positive findings that lead to an operation criterion, which are collected in the interrogation and physical examination.
5. Medical history in nursing
Nursing is a health discipline that is related to medicine and, in fact, has its own instrument or clinical format.
This is one of the clinical history models found in any health service, be it ambulatory, rural or specialized, such as in clinics and hospitals.
In terms of similarity, it is similar to the standard clinical history, but with the difference that nursing notes are collected, such as taking vital signs and placing treatment.
On the other hand, it deepens the time and shift where the therapeutic regimen was fulfilled in a patient and its evolution in a hospitalization or intensive care ward.
Other examples of clinical history
- Geriatric clinical history
- Internal Medicine
- traumatology
- phoniatrics
- Physiatrics
- Cardiology
- Neurology
- Oncology
- Hematology
- Among other.
