No Mystery Behind History

Any medical record we consider, there is a section for history of the patient. This could be past medical history or the history/story of the present illness. One might ask a question that in the world of data confidentiality, why there is a need for detailed history? Why every time we enter the clinic and history taking becomes one of the primary activities? Why it is so important for medical data management to have accurate history?

In the current would of documentation, it is very necessary to document every essential information required in treating the patient. History taking and documenting it is an art. It is very important to ask appropriate and leading questions to gather history. Information can also be collected through previous medical records. For the treating physician is can be a key for diagnosis.

What Is the Role Played by History in Medical Data Management?

In medical data management, all types of history play very important role.

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 event with its probable cause, injury descriptions in detail, complaints, examination performed recently, finding of diagnostic studies if any, investigations and treatment rendered. This information is extremely important in treating current aliment. Information gives direction to the further treatment. In data management, current illness description also plays important role in claim adjustments and sanctioning.
2. Past Medical History: It includes significant past diseases, illness, trauma, accidents or complications the patient has suffered in the past. Details in the past medical history are assessed for any correlation with current illness. Information of every aliment are captured with dates and other details during data management.
3. Past Surgical History: Past surgeries with complications if any are mentioned under this heading. Any surgical, pre/post-surgical complications are assessed during data management.
4. Family History: This section includes medical history of the parents, siblings, children or blood relatives but never of spouse or in-laws. Knowing the family medical history also helps physician to treat the patient.
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. This again helps in treating the patient.
7. Social History: This section includes patient’s habits like smoking, drinking, drug abuse, it also includes information on marital status, occupation and accommodation.
8. Psychiatric History: This is frequently lengthy and in-depth history of patient’s emotional status.
9. Immunization History: Immunizations and dates are mentioned under this history.
10. Diagnostic Studies: The review of various diagnostic studies carried out for above mentioned problems are mentioned under this heading.

Advantages Of The Medical History:

Accurate medical history is an advantage for any care given while treating the patient and understanding the importance of this history and interpreting and presenting it in the right way helps is not only treatment of the patient, but also in various other aspects related to medical field:

1. Investigational Aspect: Patient history has helped investigational aspects of the legal and criminal case.
2. Insurance: In settling the claim, medical history plays a key role. It also helps in identifying frauds.
3. Recruitments: History of the patient is an integral part of the documents required for recruitment in clinical trials.
4. Pharmacogenomics: to study genome in drug response patient’s history is a vital data that has been gattered. It is studied to better understand the biology behind diseases and drug response phenotypes.