The medical record or clinical history contains the vital information of the patient at the time of requiring medical assistance, both in consultation and in the emergency room.
This record includes personal information, family history, medical history and treatments that have been implemented.
It is the most important diagnostic tool for the physician, and it is his duty to perform it properly, since it provides the basis to proceed with what is necessary to treat the patient.
What is the medical record and its importance
Due to the great impact that the physician has on the patient’s life, it is essential that both parties are involved in order to develop an optimal record.
In addition, this document is mandatory for all physicians and is totally confidential, being accessed only when necessary.
The key to a correct clinical history is reflected in the correct diagnosis of the patient’s ailment or disease, and even in the time it takes to resolve it.
On the part of the administrative area, the patient’s clinical information or medical record is contemplated in the future in case of new consultations, generating a medical history.
In addition to this, it is a great legal support in case of any need of the patient. The clinical history is supported by the official Mexican standard of the clinical record NOM-004-SSA3-2012 and therefore must be respected as stipulated.
It contains all pertinent medical information, such as patient hospitalization, surgical procedures, intensive care, radiological images, treatments and rehabilitations.
At the end of the day, a detailed medical record speeds up care times, helps to understand the patient’s history and seeks to uphold the integrity of the physician and the patient.
Composition of a medical record: Anamnesis
The anamnesis starts from the moment the patient enters the office or emergency room, considering of importance even the way he/she does it.
During the interrogation, the patient has to refer the reason for consultation as well as personal information.
The medical record should contain the names of all those involved in the consultation, physicians, nurses, laboratory and imaging staff.
With this in mind, the preparation of a good clinical record includes the following:
Patient data: identification
This includes the patient’s full name, date of birth, residence, place of origin and blood type.
In addition to these, there are the vital signs, considering body weight, blood pressure, temperature, heart rate and respiratory rate.
Family history
The information is preferably written for parents, siblings and children. Including ages and health status.
Pathological and non-pathological personal history
The first ones tell us about surgical procedures, associated and cured diseases, past or current treatments, and allergies.
It is what has more weight at the time of new consultations, since these antecedents reflect the past and present clinical condition of the patient.
The non-pathological history is based on the patient’s daily activities, such as sleep habits, exercise, work and academic habits, diuresis, drug addictions and immunizations (vaccines).
Other antecedents, such as gyneco-obstetrics, have a place in specific areas such as gynecology, since it is unique to women.
This is why, often in the case of directed consultations such as those offered by specialist doctors, the amount of information is reduced in order to further streamline personalized care.
Reason for consultation
This section describes the patient’s complaints from the beginning until the day of the consultation.
It is not new that the electronic medical record offers many advantages to the medical service, since it allows a better and greater flow of patients.
Likewise, this type of service is associated with an excellent backup of information, easily accessible for emergencies and always stored without risk of loss.
On the contrary, the physical clinical record does not usually provide such possibilities, further deteriorating the time of care and resolution.
Hospital Management System (HIS): Grupo PTM's electronic clinical record with Medsi
PACS group and teleradiology from México in association with Medsi offers you the most intuitive, efficient and user-friendly electronic clinical record service in the Spanish-speaking world.
Supported by NOM-024-SSA3-2012 on electronic health record systems and NOM-004-SSA3-2012 on clinical records, HIS allows for better performance during medical care.
This hospital management system supports, streamlines and stores all patient information associated with a medical service, allowing health care to be provided in the shortest possible time, including any treatment applied.
The selection of questions by the physician, as well as the participation of the patient, shortens the time to solve the problem, so if there is no participation, there will be no information to treat the discomfort.
Physical examination
All the motor and sensory tests performed during the anamnesis, useful to unmask diseases in a more specific way, are written here.
Finally, imaging tests, laboratory tests, confirmatory diagnosis and, therefore, medications used and possible rehabilitation processes are added.
What is the purpose of generating the medical record?
On the physician’s side, a comprehensive medical record provides an in-depth knowledge of the patient’s state of health before and at the time of the consultation.
It helps to refer people to specialized consultations, since the medical history plays an important role.
It provides useful medical-legal protection in cases of malpractice or poor care.
The electronic clinical record versus the physical one
Earlier, we discussed the impact of electronic clinical records over physical clinical records in hospital services.
