The Clinical History: Functions, Characteristics, and Documentation
The Clinical History
Introduction
A clinical history is a comprehensive document containing all data and information concerning a patient’s health and disease, obtained through interviews, physical examinations, and additional healthcare procedures.
Functions of the Clinical History
The clinical history serves several crucial functions:
- Care: Provides information support for personalized patient attendance, enabling healthcare professionals to understand the patient’s condition and provide appropriate care.
- Coordinated Action: Facilitates communication among healthcare team members and other teams, enabling coordinated action on the patient’s behalf.
- Clinical and Epidemiological Research: Serves as a valuable source of information for disease research and statistical studies, leading to improvements in individual and community health.
- Teaching: Contributes to the continuing education of health professionals through clinical sessions and case studies.
- Medico-legal: Acts as evidence in legal proceedings involving the patient, staff, or administration, documenting injuries, complications, and provided assistance.
- Management Control and Health Planning: Provides information for quality control and facilitates better health planning by identifying areas for improvement.
Characteristics of the Clinical History
A well-maintained clinical history should possess the following characteristics:
- Completeness and Accuracy: Contains all relevant and up-to-date information.
- Retrievability: Easily accessible when needed.
- Minimum Data Set (MDS): Includes essential data points such as patient identification, demographics, diagnosis, procedures, and outcomes.
Documents within the Clinical History
The clinical history comprises various documents, including:
- Admission Sheet: Contains personal details, admission information, and initial diagnosis.
- Medical History: Includes comprehensive patient information, including personal and family history, employment data, socio-environmental factors, medication, allergies, current complaints, physical examination findings, diagnostic presumptions, and treatment plans.
- Nursing History: Documents nursing care plans, evolution of nursing care, graphics, observations, medication administration, and special checks.
- Laboratory Test Results: Includes reports of various laboratory tests.
- Pathological and Cytological Analysis Reports: Contains findings and reports of pathological and cytological examinations.
- Imaging Studies Reports: Includes reports of imaging studies such as X-rays, CT scans, and MRI.
- Consultation Reports: Documents consultations with other specialists and hospital services.
- Daily Medical Treatment Orders: Records daily prescribed medications and therapies.
- Consent Forms: Documents patient consent for special examinations, treatments, and surgical procedures.
- Preoperative and Surgical Reports: Details preoperative assessments and surgical procedures.
- Discharge Summary: Summarizes the patient’s hospital stay, including diagnosis, treatment, and follow-up recommendations.
Documents Generated in Patient Care (Not Included in the Clinical Record)
Several documents are generated during patient care but are not typically included in the clinical record:
- Health Insurance Documents: Includes membership cards and insurance information.
- Consultation and Hospitalization Forms: Documents appointments and hospital admissions.
- Medical Prescriptions: Prescribes medications and treatments.
- Ambulance Service Requests: Requests transportation for the patient.
- Medical Certificates: Certifies the patient’s health status.
- Birth and Death Certificates: Documents vital events.
Non-Clinical Documentation
Non-clinical documentation pertains to the administrative and operational aspects of the healthcare facility, including:
- Administrative Documents: Relates to economic management, billing, and inventory.
- Hospital Hotel Services Documents: Includes requests for laundry, supplies, and dietary services.
- Coordination Documents: Facilitates communication and coordination between different departments.
- Work Programming Documents: Outlines activity diagrams, task assignments, and work schedules.
- Activity Monitoring Documents: Tracks patient movement, average stays, occupancy rates, and mortality.
- General Rules and Regulations: Defines operational procedures, staff responsibilities, patient rights, and safety protocols.