PATIENT HISTORY

The Integral Part Of Medical Report

It is true ’Listen to your patient, and they tell you the diagnosis’

Modern medicine practices are ethically bound to documentation of the

data generated during patient’s treatment. Documenting complete

information of the illness and treatment has generated enormous

medical records. It can be history record/initial visit record, admission

form, operative report, follow-up visit, therapy note, pharmacy note,

discharge note or death report also. In all these reports, patient’s history is

one of the essential element which is captured.

Patient History

This term can be defined as the past information of the patient which is

medically important gathered mainly by asking specific questions to the

patient or concerned people. This has proved to be the evidence based

approach in differential diagnosis. History taking and documenting is an art.

History is normally collected by nurse or the treating physician every time

when the patient approaches the doctor for any new complaint mainly.

History of the patient is collected under various subheading, it has its own importance in the treating the illness:

1.History Of Present Illness: Current complaints, events or incidences

with relevant details are the part of history of present illness. The details

include description of the injury, complaints, examination, finding,

investigations and treatment rendered.

2.Past Medical History: It includes significant past diseases, illness, trauma,

accidents or complications the patient has suffered in the past.

3.Past Surgical History: Past surgeries with complications if any are

mentioned under this heading.

…continued

4. Family History: This section includes medical history of the parents, siblings,

children or blood relatives but never of spouse or in-laws.

5. Medicine/Drug History: Current medications with dosage and medications

taken in the past are listed under this heading.

6. Allergies: Any allergies to drugs, food, animal, dust, pollen or seasonal are

mentioned with effects seen on the patient.

7. Social History: This includes patient’s habits like smoking, drinking, drug

abuse, it also includes information on marital status, occupation, pets, habits and

accommodation.

…continued

8. Systemic Assessment: Under this subheading all the other complaints

related to body systems are included.

9. Psychiatric History: This is frequently lengthy and in depth history of

patient’s emotional status.

10. Immunization History: Immunizations from birth and yearly

immunization dates are mentioned under this history.

11. Diagnostic Studies: The review of the various diagnostic studies carried

out for above mentioned problems are mentioned under this heading.

• ‘It is said that a good history is one which reveals the patient’s ideas,

concerns and expectations as well as any accompanying diagnosis’.

• Inhibition in collecting the good and relevant medical history could

be due to inability of the patient to communicate, improper doctor-

patient relationship, unwillingness of the patient to disclose certain

information.

Computer Assisted History Taking:

• Computer technology started in 1960. It allows easy collection and

portability of the medical data saving money and paper- known as

electronic medical records.

Advantages Of The Medical History In Medical Data Processing:

Accurate medical history is an advantage for any care giver while treating

the patient. There are many advantages of accurate history data in various

other aspects related to medical field:

1.Insurance: In settling the claim, medical history proves very helpful.

Assessing the history from medical data decides the flow of the claim.

2.Investigational Aspect: Patient history in medical records plays and

key role in investigational

…continued

3. Recruitments: History of the patient is an integral part of the

documents required for recruitment.

4. Pharmacogenomics: to study genome in drug response patient’s

history is a vital data that has been gattered. It is studied to better

understand the biology behind diseases and drug response

phenotypes.

Conclusion

ITCube BPO understands the widely spread importance of medical

history. Handling all types of medical records and accurately

correlating the medical history and summarizing it, which enables the

review of those records easy and less time consuming. ITCube caters

this services to various litigation firms and TPAs, which indeed helped

them to focus more on the core business as we provide the very

precise, accurate and handy summaries saving their time to review the

documents.