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Clinical History

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Clinical history is also known as medical history, therefore, to the collection and storage of data referring to a person that are of importance to medicine. The medical history includes information about the diseases he went through, the treatments he received, etc.

A complete medical history begins with the first health check or the first medical care of a subject. The professional in question must detail his performance in the document so that the corresponding record remains. Thereafter, each new medical attention or intervention must be recorded in the medical record.

In addition to the clinical data, the file may include the patient's family history and habits. Although the general idea about medicine is that it focuses solely on physical phenomena and the state of the material parts of the organism, we must not forget that mental health is decisive in physics. For this reason, the patient's social environment, personality and interests, among other aspects, may also be part of his medical history.

The objective is that the medical history is useful for the doctor when making a diagnosis or defining an intervention. Let's look at some of the professional functions for which the medical history can be beneficial:

* teaching: although it's not a direct utility, which will necessarily serve the patient from whom it was collected, the medical history is a source of knowledge and experience that's used to enhance the skills and intuition of the medical community. Both the successes and the mistakes of each professional can become authentic lessons for their colleagues;

* research: this application resembles the previous one, in that the medical history prepared by a professional can be very useful for others. In this case, the fields towards which the work is oriented are several, since it can 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 determinants of a disease, its frequency and its distribution in a defined human population. Using the data recorded in a medical history, it's possible to extrapolate health information and profiles at regional, national or even international level;

* management and administration: health institutions use clinical records 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's important to note 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, in folders. In recent years, however, electronic medical records, which are stored on computers (computers), began to become popular.

It should be noted that storage and access to medical records are regulated in the legislation. When including personal data of patients, they are considered private and confidential documents. That's why professionals who work with the information can't disclose it or make free use of it.

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