What is a patient history?

What is a patient history?

The anamnesis is a key factor in the clinical care of patients. Having digitized medical records allows you to include health information without any limits, work with personalized profiles and carry out consultations from any device, without the need for physical space. Next we are going to explain in more detail everything about this factor and the advantages of working with clinical amanesis.

What is the anamnesis?

It is a registry of clinical data that allows health professionals to carry out health diagnoses. This has the personal data of each patient and this information not only allows reflecting the patient’s trajectory. In addition, it facilitates present diagnoses based on the information collected.

What kind of information do you collect?

The clinical history is adapted to the conditions of each patient. However, there is a series of information that is essential in all medical histories, such as:

  • Personal data: name, surname, identification numbers, date of birth, telephone, etc. It is necessary that every history sheet be identified with all the patient’s personal data that is necessary to complete their profile.
  • Reason for consultation: the health professional analyzes the symptoms perceived by the patient, as well as any information related to the reason for the consultation.
  • Medication and treatments: the anamnesis also includes the treatments and medications prescribed to the patient, as well as their subsequent reaction.
  • History: the history compiles both the patient’s previous pathologies, as well as health history related to relatives that could be of interest for future diagnoses.

These four sections are essential in any public profile, although any type of information that may be of interest to the health worker can be added.

Privacy of the content of the anamnesis

One of the basic conditions of a medical record is that it must be private and, therefore, only the patient, the health professional and the legal guardian in the case of minors, can have access to its content.

Analog histories, those that are stored on paper, need an appropriate space that guarantees their integrity and prevents access by unauthorized persons. Digitized anamnesis establish a series of conditions when granting permissions, therefore they are safer and comply with the laws that regulate data protection, provided they have an adequate storage medium.

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