The medical or clinical history is a fundamental tool for the health professional. In this post we talk about how to make a medical history: what requirements must it meet to be legal and what data must it include? After reading this post you will learn correctly how to take a medical history.
How to take a complete medical history
What is medical history
The medical history is the set of documents and computer records that clearly and concisely contains the data, assessments and information generated in each of the care processes to which a patient is subjected and in which their state of health is recorded. their clinical evolution and the care received.
The objective of history is to facilitate healthcare through current information and information recovered from previous healthcare processes.
Elements of a patients clinical medical history
Example of Rafael Neto’s clinical history
Using Clinic Cloud as medical records management software allows you to access your patients’ records from any device connect to the Internet. The information you need phone lists anytime, anywhere. Try it free for 15 days.
How to make a digital medical history
Storing and managing medical records is one of the basic tasks of a medical center. Knowing how to take a medical history and the essential conditions for its protection is important, in terms of patient care and data protection.
At Clinic Cloud we offer you a simple solution, adapt to the healthcare sector, it is a clinical records application with which you can have personal profiles, adapt to the characteristics of each patient.
Odontograms and special profiles
In addition to the basic history module, at Clinic Cloud we have special histories, such as odontograms. Traditional odontograms are very useful, but they do not offer a physical space with which to work comfortably. On the contrary, a digital odontogram like the one from Clinic Cloud allows you to add the information you want, in a digital space that is also protected, and that includes all the templates you need. If you have personaliz digital models, it will be easier to carry out diagnoses bas on detail information.
Storage and protection of confidential information.
The Organic Law on Data Protection, as well therefor as several European Forex Email List Union Directives. Establish a series of rules when storing and managing patient health information. This type of data is consider of special interest.