Disease history

The medical history is the most important document of a medical institution. It is designed to collect and summarize information about the patient. As a rule, a medical history is a patient’s medical record, which includes all information about his health status during the patient’s stay in the hospital, namely his diagnosis, diagnostic and treatment methods, medical documentation, etc.

The medical history is a kind of report from a medical institution employee to the manager. All information entered into the medical history must be accurate and objective. Errors or inaccuracies made by a medical worker can lead to negative consequences. If harm is caused to a patient, this may become the basis for bringing the employee to criminal liability. Thus, in accordance with the norms of the Criminal Code of the Russian Federation, a doctor guilty of improperly providing care to a patient has the right to be held accountable, bordering on the death penalty, for example, forcible influence on a person (Article 120).

It should be understood that such punishment is an exceptional measure that can only be imposed by a court. According to statistics, criminal liability by medical workers for causing harm to health

History of the disease: history, modernity and development prospects

A medical history is a recording and operational document that is compiled for each inpatient in a medical institution for the purpose of recording medical diagnoses, medical treatment, progress and results of treatment.

Today, medical history is an important component of the analysis of medicine and medical history. In addition, the medical record documents the medical intervention provided by the specialist to the patient and helps record medical practice. A medical history is often used in negotiations between a doctor and a patient to ensure that both parties can trust each other regarding the diagnosis and the plan of action that will be taken.

Medical History and the Development of Medicine Medical history has become an important tool in the development of medicine. It reflects the development of medical practice because it allows doctors and clinicians to make diagnoses and compare diagnostic and treatment methods with each other. Diagnostic findings and treatment results are also recorded in medical records created by a clinical laboratory, such as a pathologist, operating room nurse, clinical laboratory technician, or other nurse. Unfortunately, the method of collecting information that characterizes the current generation of clinicians and researchers often consists of comparing the characteristics of a sample of patients. Sometimes errors, usually due to inattention, accidentally distort the results of comparing patients according to medical indicators. This can lead to re-manipulation - re-analysis of previously obtained data, due to which the sample loses its purity. Nowadays, studies, including those based on case histories, sometimes reveal how few frequently repeated errors receive general recognition. Today The importance of medical history should not be overestimated. It is important to remember that while medical records themselves are necessary, they do not by themselves provide a diagnostic assessment of the disease. The diagnosis is based on a comprehensive analysis of the medical history and physical examination of the patient. Currently, the information stored in the medical history is part of the modern medical record. It is typically stored in a health information management system. There are several ways to store medical records. Previously these were ledgers, but are now often replaced by computers and databases. Some databases are similar to email transfer systems, other systems are information packets such as facsimile transmissions. Often these systems transmit images rather than data. However, most systems only work with the standard language. Each specialist in a medical institution, such as a gynecologist, pediatrician, family doctor, oncologist, has his own work programs, such that simple viewing of data by one specialist is difficult or even impossible. One of the major limitations of such databases is their inability to facilitate multiple cross-sectional comparisons of patients from the same physician, especially those who had an unusual course of disease. This drawback can become a serious obstacle to research work. As a rule, case histories contain information both about medical indicators and results, and about the patient's behavior during the course of the disease. The doctor describes the course of the disease - how it began, progressed, and what treatment was used for to cure the disease. It also includes information about the patient management process. The doctor documents all medical visits and other important facts related to the nature of the disease, the patient’s symptoms and his laboratory tests. Another important purpose of a medical history is to use it

Medical history is one of the main medical documents that are compiled when a patient is admitted to a hospital. It allows doctors to monitor the course of the disease and plan its treatment. However, the medical history may contain information that should not fall into the hands of third parties, especially in cases where the patient is a minor. In this article we will look at the main points associated with the creation and use of medical records, including requirements for the preparation and storage of documents.

1. Key points outlined in the medical history

The purpose of registering diseases is to determine medical tactics to save the patient or prescribe qualified treatment for him. Each recorded disease is entered into a special medical record.