Clinical History Documentation in Hospital and Primary Care
Clinical History Documentation
Hospital Care
Clinical history is a comprehensive record of patient information gathered during hospital care, including outpatient and inpatient services. It should contain all relevant documentation.
Structure and Order
- Patient Identification and Statistical Data: Collected upon admission, this section includes name, address, contact information, date of birth, sex, and a unique patient history number.
- Admission Sheet, Case History, and Clinical Exploration: Completed by the attending physician, this section may vary based on the specific needs of different departments.
- Evolution Sheet: This section chronologically documents changes in the patient’s condition, including date, time, and details of any clinical changes. It also includes findings from clinical sessions and reasons for changes in diagnosis or treatment.
- Order Documents: This section is divided into two parts: specific treatment orders (medication, diet, etc.) and requests and follow-up instructions. Orders must be dated, signed, and clearly indicate continuation or cancellation of previous orders.
- Allergies and Precautions: This section highlights any known allergies or necessary precautions.
- Laboratory Reports: Nursing staff incorporates laboratory and clinical test results into the clinical history. These are requested by the medical staff and completed by the laboratory service.
- Referral Reports: When consultations with other services are necessary, this section documents the request and any subsequent reports.
- Special Operation Reports: This section includes requests for specific procedures and the corresponding reports generated by the responsible service.
- Discharge Report: Prepared by the attending physician, this report summarizes the patient’s stay, including identification, service, admission and discharge dates, reason for admission, clinical history summary, test results, treatment, and recommendations. Copies are provided to the patient and the hospital archive.
- Surgical Intervention Sheet: This section is mandatory for surgical procedures and is completed by the surgeon.
- Authorization: Patients or their representatives must sign this form for access and procedures. Specific consent is required for procedures with inherent risks.
- Autopsy Protocol: This section is signed by the responsible physician and authorized by a relative. It includes macroscopic and microscopic findings, as well as the cause of death.
- Other Sheets: This section may include urgency reports, patient-provided data, voluntary discharge requests, etc.
Patient Rights
- Confidentiality of medical history.
- Restricted access to authorized personnel.
- Anonymity in publications.
- Limited removal of clinical history from the hospital.
Nursing Record
The nursing record includes:
- Initial Organizational Structure: Completed by the nurse upon patient admission.
- Care Plan: Documents the patient’s care needs and is updated throughout their stay. Records are made for each shift.
- Medication Administration Sheet: Records medication, route, time, and dosage. Nurses are responsible for accurate administration according to medical orders.
- Chart with Vital Signs: Accurate completion is the responsibility of nursing staff.
Clinical History in Primary Care
Primary care clinical history records an individual’s health and development throughout their life. It provides information on health and disease processes, ensures continuity of care, facilitates family health monitoring, enables community health data collection, identifies risk factors, supports planning and evaluation of activities, and serves as a research and documentation tool.
Model HC AP
- Biopsychosocial approach.
- Multiple contacts with the patient and family.
- Health promotion and prevention activities.
- Multidisciplinary care.
Fundamental Elements of AP HC
- Patient data and problem identification.
- List of health problems.
- Action plan for each problem, including education and necessary tests.
- Progress notes for each health problem.
Documents in AP HC
- Pilot sheet.
- Family sheet.
- Personal problem list.
- History and exploration sheet.
- Monitoring sheet.
- Consultation sheet.
- General data and identification sheet.
Central Archive of Clinical Histories
This service is responsible for maintaining and safeguarding clinical documentation.
Difference Between Hospital and Primary Care Clinical History
Hospital Clinical History
- Focuses on disease.
- Diagnosis-oriented.
- Treatment-oriented.
- Collects specific health changes.
- Created for health recovery activities.
- Less continuity in the doctor-patient relationship.
Primary Care Clinical History
- Focuses on health problems.
- Problem-oriented.
- Solution-oriented.
- Collects data over time.
- Includes prevention and health promotion activities.
- Emphasizes social and family factors.
- Greater continuity in the doctor-patient relationship.