The concept of history can refer to the presentation of past events or events that happened to an individual in their life. The clinical , meanwhile, is that linked to medical practices .
Known as medical history , therefore, the collection and storage of data referring to a person that is of importance to medicine . The medical history includes information about the illnesses you experienced, the treatments you received, etc.
A complete medical history begins with the first health check-up or with the first medical attention of a subject. The professional in question must detail their actions in the document so that the corresponding record remains. From then on, each new medical care or intervention must be recorded in the medical record.
In addition to clinical data , the file may include the patient's family history and habits . Although the general idea about medicine is that it focuses only on physical phenomena and the state of the material parts of the organism, we must not forget that mental health is a determining factor in physical health. For this reason, the patient's social environment, personality and interests, among other aspects, can also be part of their clinical history.
The objective is for the clinical history to be useful to the doctor when making a diagnosis or defining an intervention. Let's look at some of the professional functions for which medical history can be beneficial:
* teaching : although it is not a direct utility that will necessarily serve the patient from whom it was collected, the clinical history is a source of knowledge and experience that is used to enhance the skills and intuition of the medical community . Both the successes and mistakes of each professional can become real lessons for their colleagues;
* research : this application is similar to the previous one, in that the medical history prepared by a professional can be very useful to others. In this case, the fields towards which the work is oriented are various, since it may be the search to improve the work tools of a clinic or the study of a disease, for example;
* epidemiology : this is the discipline of science that focuses on the study of the determining factors of a disease, its frequency and its distribution in a defined human population. Using the data recorded in a medical record, it is possible to extrapolate health information and profiles at a regional, national or even international level;
* management and administration : health institutions use clinical history as one of the elements to evaluate the performance of their professionals. Through this document they can make decisions that affect the general organization and the characteristics of the services they offer if necessary.
It is important to highlight that the medical history not only benefits the doctor, his colleagues and the health institution for which he works, but also the patient. This record of the relationship established between both parties is one of their fundamental rights , one of the pillars on which health services are built.
For a long time, medical records were stored on paper , inside folders. In recent years, however, electronic medical records , which are stored on computers , began to become popular.
It should be noted that the storage and access to medical records are regulated by legislation . By including personal patient data, they are considered private and confidential documents. That is why professionals who work with the information cannot disclose it or make free use of it.