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 patients 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, patients 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 patients 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

patients 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 patients 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 patients

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.