History is a key factor in clinical patient care. Having digitized medical records allows you to include unlimited health information, work with personalized profiles and carry out consultations from any device, without the need for physical space.
The anamnesis is a record of clinical data, which allows health professionals to carry out health diagnoses.
The anamnesis or medical history has personal data of each patient. This information not only allows us to reflect the patient’s trajectory, but also facilitates the present diagnoses based on the information collected.
Personal data: Name, surname, identification numbers, date of birth, telephone number, etc. It is necessary that every anamnesis record be identified with all the patient’s personal data that are necessary to complete the patient’s profile.
Reason for consultation: The healthcare professional carries out an analysis of the symptoms perceived by the patient, as well as any information related to the reason for the consultation.
The anamnesis and the diagnostic process
Anamnesis is a fundamental principle for diagnosing diseases in patients. If there is no historical information. The diagnosis is provisional and must phone leads for sale include subsequent confirmations that ensure. The accuracy of the original diagnosis.Consultation and development of medical history
The environment that the patient perceives in the medical consultation is a key factor in completing a history. We receive much of the health information through the patient’s own testimony, which is why it is essential to offer a private space, based on trust.
The clinical interview includes four essential phases to obtain the necessary information:
Preparation: The environment that the patient finds in the consultation must be appropriate; prior preparation includes the study of the history and the conditioning of the space.
The privacy of the content of the anamnesis
One of the basic conditions of a medical record is that it must be private, and therefore.Only the patient, the health professional and the legal guardian in the case of minors. Can have access to its contents
analog records, that is, those stored on paper, need an appropriate space. That guarantees their integrity and prevents access to unauthorized persons. Digitized anamnesis establishes a series of conditions when granting permissions. Therefore they are safer and comply with the laws that regulate data protection, as long as they have adequate storage media.
Both Spanish law and European law Country List establish a series of imperatives. That try to protect patient privacy as we analyze below. Digitized records are more appropriate to guarantee security against possible unauthorized queries.
Clinic Cloud is a healthcare software that allows you to create personalized clinical profiles for patients.