The structure of the case history by therapy is the fruit of many years of efforts of specialists from different countries. This medical document includes many sections. Moreover, there is currently a universal medical history for therapy. Bronchitis, coronary heart disease, gastritis - for patients with all these ailments, the history of the same format is started today. This greatly facilitates the work of doctors and reduces the cost of purchasing consumables.
"Front" side
Here the patient's data such as last name, first name and patronymic are indicated. In addition, information is also entered here about which ward he was placed in, as well as the date the person was admitted to the hospital and discharged from it.
Also, in many hospitals, on the front side, they indicate how the patient was admitted (applied on his own or was delivered by ambulance) and whether the diagnosis of the referring organization (clinics, ambulance teams) coincides with the final one.
Passport part
The structure of each case report by therapy includes this section. More detailed information about the patient is recorded here. His passport data is entered here, including his "full name", personal number, address of registration and real residence, phone number of one of his close relatives. In addition, the name of the sending organization is also indicated here.
Patient complaints
Here are those subjective symptoms that are voiced by the person himself upon admission to the hospital. Often this point is uninformative. However, it also happens that it turns out to be more useful than others. So it is customary to pay special attention to him.
History of present illness
Here you need to enter information about how the person fell ill, what contributed to this. In many cases, it is possible to establish the correct diagnosis already on the basis of this one point in combination with the previous one. At the same time, you should not limit yourself to only these two sections.
Life Story
Here it is necessary to briefly describe the conditions under which human development took place. Information about the patient's current living conditions may also be very useful.
General inspection
This item is one of the most important and extensive. This describes how the patient was examined. Moreover, it is necessary to conduct a study of all systems of human organs (if possible, of course). Unfortunately,many specialists (often even experienced ones) do not pay due attention to the general examination, concentrating only on the problem that the patient himself complains about. This approach is not always correct, because often a person has concomitant diseases that do not yet have significant severity, but in the absence of treatment they can progress.
Lab data
To make a correct diagnosis, this point in the medical history of therapy is of particular importance. The fact is that the fact of the presence of many ailments can only be established on the basis of laboratory data.
Substantiation of the diagnosis
It is established on the basis of complaints, anamnesis, laboratory data and general examination. That is, only after the patient is thoroughly examined.
Treatment
Here are those activities that, in the opinion of the doctor, will get rid of the existing disease.
Diaries
This paragraph briefly indicates the data of the patient's periodic examinations, indicating his condition and the dynamics observed during treatment.
Discharge summary
Any finished therapy case history includes such a section. The discharge summary is written so that other medical facilities, when a patient visits them, know that a person has suffered a particular disease. This section is a summary of the entire medical history by therapy. There should also be detailed information about the patient: full name,how old he is, how and with what complaints he entered the hospital, what are the features of his anamnesis. In addition, the epicrisis records data on the results of basic laboratory tests and ongoing treatment, makes a final diagnosis and indicates when and in what condition the patient was discharged.
