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medical history


The Medical Record is a medical-legal document in which one writes pathologies of the patient, is used for data collection and this belongs to the patient and the health institution of attendance.
The history should be written legibly in ink color and black, that is understandable to other health care professional who reads and judicial.En level cases it has value that is written and what was omitted has no value.
History clinker is constructed as follows:
Your Medical Record Number:
With the full name of patient:
Date of Birth:
Address:
Phone:
Email: Check Reason
:
Type Housing:
Family Type: Type of Community
where you live:
Personal Background: Pathologic
Background:
Family History of Pathology: Physical Examination
:
drugs you take, how many for days, how many doses, how many grams:
Type Diet Patient:
Studies Laboratory, Diagnostic Imaging:
Notion of Focus: The History
Clinic Pediatric Patients taking into account the perinatal and postnatal antecedents, type of vaccines received, written and describes the psychomotor skill . After six years of age, the girl's medical history is different from the medical history Males of Health
Each institution, has its own medical history for which itwould they vary in form and structure.
It is the Family Health History and Social History Patient Clinic
Note: In case of emergency care, first you write it and then writes the other items