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DeGowin's Diagnostic Examination, 9e
Chapter 2. History Taking and the Medical Record
Sections: History Taking and the Medical Record: Introduction, Outline of the Medical Record, Procedure for Taking a History, Completion of the Medical Record, The Oral Presentation, Other Clinical Notes, The Patient's Medical Record, Electronic Medical Records.
Topics Discussed: medical history; medical record, device.
Excerpt:"Proper care of a patient for more than a single episode of care requires a medical record documenting the data specific to the patient and their care. Ideally, this record should be available to all providers at any site of care at any time, an ideal within grasp with electronic medical records. The record should contain, preferably in standardized formats, basic patient data, such as their demographics, list of active and past medical problems, surgical history, injury history, medication history, allergies, and drug intolerances, sexual history, family history (FH), social history (SH), personal habits, prostheses used, preventive care services, and specific counseling provided. Using standardized forms for data acquisition and filing enables the information to be recorded in a uniform way for each patient, allowing rapid review of the pertinent information at each visit. It is important to enter information in such a way that it is always current; for example, in the FH list the first names of children and siblings with their year of birth (rather than age)...."
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