Learning to fill out medical history by therapy

The structure of the medical history of therapy is the fruit of many years of efforts by specialists from different countries. This medical document includes many sections. Moreover, at the present time there is a universal medical history of therapy. Bronchitis, ischemic heart disease, gastritis - the patients of all these ailments are now starting a story of the same format. This greatly facilitates the work of doctors and reduces the cost of purchasing supplies.

"Front side

Here are the patient's data such as last name, first name and patronymic. In addition, information is also included here regarding the room in which it was placed, as well as the date of admission to the hospital and extracts from it.

Also in many hospitals on the front side indicate how the patient acted (turned himself or was taken by ambulance) and whether the diagnosis of the sending organization (polyclinics, ambulance teams) coincides with the final one.

Passport part

The structure of each medical history for therapy includes this section. More detailed information about the patient is recorded here. This is where his passport data is entered , including "full name", personal number, address of residence and real residence, telephone of one of close relatives. In addition, the name of the sending organization is also indicated here.

Patient Complaints

Here are indicated those subjective symptoms that the person himself voices when entering a hospital. Often this paragraph is of little informative. However, it also happens that it is more useful than others. So he was taken to pay special attention.

The history of this disease

Here you need to enter information about how a person fell ill, that contributed to this. In many cases it is possible to establish the correct diagnosis already on the basis of one of this item in combination with the previous one. At the same time, only two of these sections should not be limited.

Life story

Here it is necessary to briefly describe the conditions under which human development took place. Information about the patient's current living conditions may also be very useful.

General inspection

This item is one of the most important and extensive. This describes how the patient was examined. And it is necessary to conduct research of all systems of human organs (if possible, of course). Unfortunately, many specialists (often even experienced ones) do not pay enough attention to the general examination, concentrating only on the problem the patient himself is complaining about. This approach is not always correct, because often a person has co-morbidities that are not yet significant, but in the absence of treatment they are able to progress.

Laboratory test data

To make the correct diagnosis, this point of the medical history is of special importance for therapy. The fact is that the fact of having many ailments can only be established on the basis of laboratory data.

Justification of the diagnosis

It is established on the basis of complaints, anamnesis, laboratory data and general examination. That is, only after the patient has been thoroughly examined.

Treatment

Here, those events are described, which, in the opinion of the doctor, will make it possible to get rid of the existing ailment.

Blogs

This paragraph briefly indicates the data of periodic examinations of the patient, indicating its state and dynamics, observed against the background of treatment.

Write epicrisis

Any ready-made medical history of therapy includes such a section. A written epicrisis is written in order that other medical institutions when they visit their patients know that the person has suffered a particular disease. This section is a brief description of the entire medical history of the therapy. Here should be detailed information about the patient: name, how old is he, how and with what complaints he entered the hospital, what are the features of his anamnesis. In addition, the epicrisis records data on the results of the main laboratory tests and treatment, put a final diagnosis and indicate when and in what condition the patient is discharged.