Patient History
The patient history is a record of what has happened to the patient since birth. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease status. The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members are recorded. It includes several subsets detailed below.
Patient History is recorded under two broad classifications, Personal History & Medical History.
Patient History
Personal History
This section is used to capture and maintain health habits, smoking, social and family history, travel history including the capture of pertinent postive and negative histories which are patient reported or from externally available patient clincial history.
Update Record
Personal history is another way to enter consultation on a patient. To add Personal History, Select a Patient Record >> Patient History >> Personal History. Record Helath Habits, Smoking, Travel History, Family History and Social History. Click Save button to update the entries.
Medical History
Individual medical encounters are marked by discrete summations of a patient's medical history by a physician. Each encounter will generally contain the following aspects like Ongoing medical problems and treatments, Major events, hospitalizations, surgeries under gone, drug allergies, immunizations, and medications done previously are noted here.
Update Record
To add Medical History, Select a Patient Record >> Patient History >> Medical History. Record Past Medical History, Ongoing Medical Problems, Drug Allergies, Immunizations and Medications. Click Save button to update the entries.