Alberto J. Muniagurria
The recording of the information obtained, in the doctor-patient interview, through the interrogatory, the physical exam, and also the results of the clinical laboratory studies, as well as those of diagnostic imaging, is known as a Clinical History. It collects the information necessary for the complete care of the patients. The recording of the information obtained in the interview includes medical indications, daily evolution, nursing notes and the Epicrisis or final note.(in the Institutional Chart)
The record of the CH builds a main document in a health information system, essential in its healthcare, administrative aspect, and also constitutes the complete record of the care provided to the patient during their illness, from which its significance as a document is derived legal. In other words, by registering it, builds a document with legal validity (that is, before the courts). If it is not registered, it is an undocumented medical history (without legal validity, only testimonial)
It serves to register the Clinical Method (Methodological order of evaluation of a patient). F Follows the order of the clinical method, semiological order of work.
The CH or clinical record constitutes a valid legal medical document, which contains information covering the patient's healthcare, preventive and social aspects.
It is the basic record or database that contains the information of the doctor's work.
It fulfills various purposes. The collection of data, which when ordered helps to build knowledge about the patient, to guide the diagnosis of problems, to reason and establish a line of studies and diagnostic and therapeutic procedures. It is an essential instrument for intercommunication between the members of the health team, for the comparison and successive verification with the information that is being incorporated, to obtain statistical studies, carry out research and autopsy confrontation .
The CH is opened for knew information and always originates with the first episode of health or disease control in which the patient is treated, either in the public or private hospital, the Assistance Center or in a Medical Office.
As of today, the patient has as many stories as there are institutions where he consults. With the advancement of data recording methods, it is not difficult to imagine, in the near future, that information will be kept in a single database with universal access.
The Record of the CH builds a main document in the hospital information system, essential in its healthcare, administrative aspect, and also constitutes the complete record of the care provided to the patient during his illness, from which its significance is derived as a legal document.
The C H is part of the science of Clinical Semiology. It must be true, complete, understandable and coherent and follow an order or regulation that makes the common language of doctors.
With experience, a more specific CH can be developed, but never incomplete. There is no lack of data, which, although negative, have a clinical hierarchy. It must be transcribed in logical order, without inducing, crossing out without clarifying, or blotting in the writing in the description of the data, especially since it is an instrument with legal value.
Time is short in outpatient consultation and is sometimes a natural enemy of thoroughness in data collection. When making the history with the inpatient, the available time is greater. In some healthcare facilities, a pre-printed form is used, which must be completed by the patient before the medical consultation. This subtracts necessary human contact from the doctor-patient relationship.
The suggested order to carry out the complete CH (clinical method) in hospitalization, which is oriented to build a list of problems is:
Basic information: Interrogation, Physical exam, Clinical Laboratory, Diagnostic Imaging, Special studies
List of Problems
Diagnostic discussion, evaluation plan and patient education for each of the problems
Nursing Notes and Charts
Epicrisis or note of externalization
BASIC INFORMATION: INTERROGATORY or anamnesis
The interrogation or anamnesis is the first step in the preparation of the clinical history. It is one of the most important skills available to the doctor, and can very often provide the data (Subjective or Objective, Symptoms or Signs) that define the clinical picture.
It can be done to the patient who consults or to an observer who is a witness to his illness, such as a family member, neighbor or occasional witness. The content must be comprehensive, including the reasons for the consultation, both in the body and in the mind. All significant events in his health, in the Bio-Psycho-Social aspects, of his life are ranked.
It usually begins by letting the person spontaneously state their reasons for consultation, with only interruptions to avoid dissociations or the loss of the thread of thought. It is extremely important to know how to listen, allowing oneself to intervene only when clarity can be provided, to what the patient narrates.
The facial expression of this, his tone of voice and the way of speaking, his attitude, are giving keys to guide the diagnosis and to detect the meaning and importance of the symptoms. By listening, one learns not only about the disease, but also about the sick.
While the information is being obtained, the voice, language, intellectual level, expressive capacity, etc. will be evaluated.
As the interrogation develops, the dialogue should be noted, in a prudent way, so as not to demonstrate loss of attention. Attitudes such as frequently looking at the clock, or repeating questions already asked should be avoided. This behavior transmits security and limits the anxiety of the consultation.
After a reasonable time, letting the person speak, the doctor will initiate the directed questioning , which should not be induced, but clearly objective. This way of questioning is guiding the problems posed by the patient and their possible causes (diagnoses).
During the course of it, different diagnostic hypotheses originate and accept or reject, which will later be confirmed or discarded in the subsequent study of the patient (inductive-deductive). This evaluation of the patient will depend to a great extent on the information obtained in the interrogation.
In the registry it is necessary to maintain a logical order of the narration, trying to group the different symptoms and signs such as syndromes and problems that must then be followed and solved.
The objective of the clinical method is the etiological diagnosis (I know), but the starting point is an isolated fact. These isolated data (Symptoms and Signs) or problems should be questioned to obtain, from them, as much information as possible, such as place and form of origin, intensity, time of appearance, variations with physiological phenomena (breathing, digestive, muscular movements, etc. etc.) One by one the data must be questioned in detail. The anamnesis contains 50% of the keys to reach the diagnosis.
If the questioning is taken chronologically, recent episodes should be ranked and receive the most attention. If the problem history medical guidance system is used, those problems that are dominant should be considered first.
The doctor learns, through experience, to know the difficulties that arise, by doing a good questioning, and it is here where the knowledge, practice, and skill of the professional are most clearly manifested. Likewise, the capacity for synthesis, which is acquired with practice time, gives an advantage to the experience. On the other hand, the interrogation, the initial part of the medical interview, and the opening of the medical history, constitutes the fundamental means to begin and expand the relationship with the patient, gain trust and obtain his collaboration.
It is necessary from the beginning of the dialogue to separate the acute reasons for consultation , which must be resolved relatively quickly, from the chronic ones , which require a calmer order for their control and follow-up, and from health controls , which have their organized scheme of medical intervention, that is, there is a different medical intervention in each case.
There are several models of medical history:
The classic one or traditionally used in Hospitals, Sanatoriums or Outpatient Centers. In practice it can be divided into hospitalization and outpatient
The Problem Oriented Medical Record (PPOMR) . Registration model that is used in Primary Care and Family Medicine services that is oriented to approach the patient in a holistic, comprehensive way and that, despite valuing the diagnosis, rescues as problems those bio-psycho-social situations that are not they come to define etiologically. It was described by Dr. Lawrence L. Weed in 1968, and incorporated by the Chair of Clinical Semiology of Rosario since 1980.
The protocolized Wich includes closed questions, it is used to monitor very specific and limited diseases in specialized units. It is often used by medical anesthetists.
Basically the clinical history currently has two types of supports:
Written on paper: Includes a series of sheets or forms that are arranged in a folder. It can be individual or family.
In computing through programs specially designed by various programmers for institutions or in commercial offerings. It is called electronic medical records stored on computers using software generally use a program of outpatient and other internment . The immediate and timely availability of all the necessary information, their transportation from one area to another, for diagnostic and / or therapeutic decision-making, make these systems a very useful weapon.
The usual order followed in the preparation of the interrogation is:
1.1 Personal Data
Personal data should be noted in the heading of the medical record. The name, address, telephone number, gender, age, occupation, race, nationality, religion, marital status, document number and the name of the referring physician. Each of these data, which frame the patient, and their cultural customs, provide medical information of their own. The different incidences of pathologies and etiological agents according to age, sex (gender), race is clearly known. An example is the incidence of Ewing tumors in childhood, and of the lung in adults, and of breast in women. The incidence of Pneumococcus as a cause of meningitis in children, and Haemophilus Influenzae in adults, endometrial cancer in women without sexual activity and cervical cancer in sexually active women. The incidence of hemolytic anemias in Mediterranean populations, stomach cancer in Japanese, or occupational diseases or in groups with eating and living habits, which are guided by the various religions, should also be mentioned. In turn, the patient will need the spiritual support of his parish priest, rabbi or preacher during his illness, and therefore, recognizing his religion allows us to better manage the integrity of the human being.
The source of the information must be recorded, which may be the patient himself or his representative.
1-2 Reasons for Consultation/Chief Complaint
It is the reason or reason (Symptom, Sign, Syndrome, Diagnosis or Problem) that leads the patient to request the opinion of the doctor. This is what leads him to request an interview with the health professional. It must be noted as the headline in the news story and in general, with the terminology used by the patient. (health check up, tiredness, shortness of breath, etc., etc.)
1-3 Current disease
The current illness is the narration of the reason for the consultation. In an orderly, logical, grammatically correct way, the data that mobilized to seek the opinion of the physician will be described one by one. This should be developed with the data provided as with those that, due to their absence, are important and contribute to the understanding of the different problems.
A logical sequence should be followed, and as far as possible organized and oriented in groups of symptoms, signs and problems. The time of the appearance of the data should be noted, marking the last opportunity when the patient felt good.
The information is noted in chronological order, indicating the dates on which the data are incorporated. In long-term diseases, it is useful to record the ages of the patient at the different moments of the disease.
A good practice is to use different paragraphs for each chronological period of the current illness, indicating the time of each one of them. (One month before the consultation ...). Each symptom is described in what it does at the beginning, presentation characteristics, evolution and course, without leaving it until all the information regarding it has been collected.
In this way, two lines of description are followed: that of the Symptoms and Signs, and that of the dates on which they occur.
Symptom / Sign Analysis
Symptom is what the patient fills an Sign is what could be observed
Each Symptom or Sign must be carefully worked to obtain the maximum possible information. The truth may be hidden or confused, simply, for not having gone deep enough in the search for information
It is valid to remember a systematic order to follow in the questions:
Characteristics of the Symptom / Sign: The location, the irradiation (in the case of pain), the character, or the quality, intensity and severity, factors that improve or aggravate it, the temporary character (continuous or intermittent) and the accompanying symptoms and signs.
Full length of episode
Starting way: Inquire about the starting date, time if possible and how it started, (gradual or sudden) and the precipitating factors: emotions, exercise, fatigue, organic functions, pregnancy, environment and physical factors such as heat and cold, trauma, stress, infection, exposure to toxins, allergies, responses to drugs etc. etc.
Carried out from the beginning: describe its incidence (acute, chronic or recurrent, chronic and continuous attack, daily or periodic); its progression (for better, for worse, or without changes) and the results of the treatments carried out.
It is necessary to take note of all the therapeutic measures used in the process, both medicinal and non-medicinal, and record the name of all the medicines used, quantity, duration of treatment, results and possible side effects. It is essential to describe all hospitalizations related to the Symptom / Sign.
1-4 Personal history
In this section of the interrogation, all episodes that affected the patient's health from birth are noted. A summary of the previous hospitalizations is made, although without repeating information that was already included in the current disease.
For each admission, the admission and discharge dates and a summary of the problems addressed in that episode must be recorded. The findings arising in that circumstance, operations, evolution, treatment results and final diagnoses should be included.
Should ask about the presence of allergies, reactions to drugs, foods, such as milk and cereals, if you have had episodes that appear to be hay fever, eczema, hives or serum sickness, and take note, especially in children, older adults and in patients who travel to special areas their vaccination status, dates of application and reactions to them. It is important to investigate infectious diseases such as lung diseases, pleurisy, tuberculosis, etc. and on previous surgical interventions, injuries from trauma or other diseases of childhood or adulthood.
Questions should be asked about activities in mental, social, corporate, military institutions, etc., etc.
1-5 Personal habits
In this section information is obtained on customs (travel) and habits such as sleep, habitual diet, diuresis and catharsis, cigarette, alcohol, drugs and self-medication, use of seat belts, prophylactics in their links and your sexual preferences.
Always should be ask about aspirin, which is not considered a drug by the population; it is of interest to inquire about levels of education and occupational history, with its risk factors (Asbestosis, Lead, Radiation, etc.)
The environment where it lives, the customs of personal hygiene, the knowledge of the vinchuca (parasite related with Chagas Disease) and other parasitosis are important. The patient's psychological reaction to the disease must be evaluated, that is, the understanding of the disease and his/hers attitude.
1-6 Review of organs and systems
This section of the Medical Record is intended to complete the information that may have been overlooked in the current Disease. Symptoms and signs already evaluated should not be repeated.
In the review of organs and systems it is convenient to ask yourself an order of questions, so as not to lose information. It asks about symptoms and signs of skin, head, eyes, ears, nose, paranasal sinuses, oral cavity, neck, nodes, breasts, cardiorespiratory, digestive, urogenital, endocrine, limbs, central and peripheral nervous system and hematopoietic.
In women, note the age of onset of menstruation and breast development, menstrual periods, with duration, quality, and associated symptoms; pregnancies, miscarriages, and miscarriages; climacteric and symptoms of heat, nervousness, fatigue etc.
1-7 Family history
This section asks about all those diseases that may have a hereditary or genetic link with the patient. Parents, grandparents, siblings and children should be questioned. This will be developed more thoroughly if suggested by the patient's illness, for example about his sexual partners. The information about the couple who live together provides psychosocial and infectious data. If a relative died, take note of the age and the cause.
Physical examination (PE)
The physical examination is carried out after the interrogation, following a methodological order and must be carried out completely. That order is as follows:
Inspection, Palpation, Percussion, Auscultation, Gynecological and Rectal Touch, Ophthalmoscopy and Otoscopy.
In practice, the inspection starts and will provide data from the beginning of the consultation.
The normal or abnormal findings found constitute the Signs, or objective facts, markers of health or disease, which may or may not confirm the suspicion caused by the history. Sometimes the sign found is the only manifestation of the disease, such as a breast nodule.
The PE is understood pedagogically as a skill, but it is not only part of it, since it is part of a line of knowledge, which can vary from patient to patient. Hearing a murmur is a skill, but an understanding of what it means, its definition and clinical setting, as well as the suitability to the case of the patient in question, type of consultation, if it is a routine consultation or an emergency, "requires an adaptation to the circumstance that exceeds the limits of skills and requires information and knowledge of anatomy, pathophysiology and knowledge of medical/patient relationship.
Findings or Signs, normals as well as abnormal, from the PE should be recorded or recorded regularly. These can change or disappear, which makes it important to repeat it periodically as many times as necessary.
Over the years, the increase in the number, availability and precision of complementary laboratory tests have led them to trust and rely on them for the solution and definition of clinical problems.
These studies are, of course, important, and in particular form the basis of screening programs for the early diagnosis of various diseases.
Most of these tests are not perfect, and can sometimes make a healthy person sick or fail to detect pathology. Therefore, it is of utmost importance in evaluating the results obtained, to take into account the limitations of these studies. Should be remember that they are impersonal, they have the possibility of technical errors, and of interpretation, which undoubtedly requires working with a quality controlled service.
The imaging such as Conventional Radiology, Ultrasound, Radioactive Isotopes Endoscopies, Conventional Radiology, Scintigraphy, Axial Computed Tomography (ACT), Nuclear Magnetic Resonance (NMR), Doppler, PET Scan, Tomography Multislice, Virtual Endoscopies, Diagnostic Laparoscopy etc., contribute to study the patient and provide important information to establish a diagnosis, define the anatomy of the lesion, as well as follow the evolution.
It is important to emphasize that the same reserves must be applied in these studies as for the Clinical Laboratory. The sensitivity, specificity, prevalence as well as the cost of the procedure must be evaluated in relation to the information they provide. Consideration should also be given to the changes in behavior to be followed, provided by carrying out the study, as well as having a very clear reason for doing so. The massive use of analysis does not relieve the doctor of his responsibility to interrogate and examine the patient and recognize and observe him as a whole.
Evidence-based medicine has contributed its share of utility in recognizing the diagnostic value of results or data.
(a) Is a Study o r Medication in which the preponderance of the data supporting this result is derived from level 1 studies, which cover all the evidence criteria for that type of study.
(b) Is the one in which the preponderance of the data supporting this result is derived from level 2 studies, which cover one of the evidence criteria for this type of study.
(c) Are those in which the preponderance of the data that supports that result, are derived from 3rd level studies, which do not have evidence criteria for this type of study or are based on the opinion of supported experts in their experience, or in consensus of opinion and not verified with scientific method.
A reason for consultation or a finding on the physical examination will guide the studies to request. In the case of an abnormal result in a patient who does not present any symptoms and no signs of review, the study should be repeated to rule out an error. If the abnormal result is repeated, the clinical judgment will indicate the conduct to follow.
In the CH of hospitalization it is important to unify the language in the notes of daily evolution. Lawrence Weeds recommends writing down the Subjective (SYMPTOMS) data of the patient first, then the Objectives (SIGNS) of the clinical examination, and finally writing down what is planned to be done (Indications, Treatments, Consultations, etc.).
It is of great interest to unify the order, or sequence of indications. This is of great impact on the quality of care, not only of the doctors but of all the members of the health team (nursing, pharmacy, audit, kinesiology, etc.)
The suggested order is first of all the patient's problem or diagnosis
- Problem or diagnosis
- Activity (absolute, relative rest, etc.)
- Diets (general or specific)
- Interconsultations - Studies requested - Preparation of the patient for surgery etc.
- Vital signs and schedule control
- Hydration plan with its electrolyte content
- Analgesic medication, for sedation and / or for catharsis
- Medication with dosage, route of administration and schedule
List of Problems or Diagnostics
Problems and Diagnostics are listed in order, including:
- Symptoms and signs (fever, pain, etc.)
- Syndromes (heart failure, gastrointestinal bleeding, etc.)
- Diagnoses (diabetes, blood culture (+), etc.)
- Psychological and social problems (divorce, depression, panic, etc.)
- Risk factors
- Abnormal test results
Nursing Notes and Charts
Nursing must have a space to record their observations, controls, and their execution schedule, given the importance of their participation in patient care.
It is a summary of what has been done, including studies carried out, treatments and results at patient discharge.
The CH must be filed and go to a Central and Unique Archive of the Hospital or Health Center for its corresponding protection. It is the responsibility of the Hospital Administrative System to carry on this properly.
The Institution timely delivers it to the different professionals who request it. Computerized systems facilitate filing and easy access to them,
Regarding the ownership of the medical record, in case of legal conflict, and once the record is claimed by the judge, it becomes judicial property with all its consequences. A copy could be given to the patient, if he /she asks for
Professional secrecy extends to physicians, nurses, physical therapists, occupational therapists, nursing assistants, podiatrists, caretakers and administrative personnel, as well as the auxiliary personnel of the Hospital.
Maintaining patient confidentiality and privacy primarily involves the medical record, which must be properly guarded, remaining accessible only to authorized personnel.