A patient’s medical history consists of several components of information that conveys the complete details of an individual’s present and past health condition. A complete record of medical history should constitute the following information:
1.Diagnosis:
It is important to know the medical condition that the individual has. For example, does the individual suffer from depression, hypertension, mental retardation, diabetes, heart disease, cerebral palsy or any other medical or mental health problems?
2.Current Medications:
It is a record of all the names and doses of the medicines that a patient takes.
3.Allergies:
It is important to make a note of the allergies that a person has. This could include, allergy to medicines, food, dust, pollen, etc.
4.Medication history:
What medicines does the patient take? This includes OTC (over-the-counter) and prescriptions medications that the person may have taken. A documentation of when the medicine was started and stopped needs to be obtained as well.
5.Current and past Illnesses:
Information regarding any serious or chronic illness that the person has suffered from or suffering from, for example- if the patient has had diabetes or cardiac disease.
6.Doctor Information:
This includes the names of doctors from whom the patient may have previously received treatment from. Names, specialty of the physician, phone numbers of the patient’s current medical service providers and other healthcare professionals.
7.Emergency Contact Details:
Emergency details include the names and telephone numbers of family member or friends who could be contacted in case of a medical emergency. This is especially helpful if a person suffers from medical condition such as ‘Fits’ wherein he has no control over himself and needs external help.
8.Surgeries Undergone:
Information of previous surgeries is relevant as they provide you information regarding the seriousness of a particular health condition. Also, it helps determine the correct line of treatment. For example, if a woman has undergone a surgery for uterine fibroids and has her ovaries removed, it would be necessary that she receive hormonal therapy post operation in order to correct the hormonal imbalance.
9.Hospitalization History:
It is equally important to know why a patient was hospitalized. What were the reasons for his/her discharge? Was the discharge sanctioned by the treating doctor or whether a patient requested a transfer from one hospital to another for better services?
10.Family’s Medical History:
Collective information of a person’s familial conditions such as a history of heart problems, diabetes, cancer or mental illness can assist in better treatment of an individual’s medical condition.
11.Details of Medical Cover:
This is of immense benefit for the patient as he/she may claim for a reimbursement related to hospitalization or treatment of a specific health condition. Medical Insurance details are required by hospitals to help in smooth transaction and processing of payments.
12.Immunization Schedule Details:
A detailed record of the immunization schedules that a patient has received along with the dates on which the immunization were given.
All this information can come from various sources and by compiling them into an easily accessible folder, your doctor, healthcare provider as well as you, can easily access this information. Since an individual’s medical history may change over a period of time, it is necessary to keep your information updated. When an individual is diagnosed with a new health problem or starts taking a new medication, it should be recorded in their medical history.An updated medical history will thus provide a doctor with all the necessary details to effectively diagnose and treat the medical condition of his/her patients.
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