The anamnesis is a key factor in the clinical care of patients. 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.
Next, we analyze the use and advantages of working with clinical anamnesis.
What is the anamnesis
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 reflecting the patient’s trajectory, it also facilitates the present diagnoses based on the information collected.
What information does the clinical history collect
Personal data: name, surname, identification numbers, date of birth, telephone, etc.
Reason for consultation Special Trade Contractors Email List the healthcare professional analyzes the symptoms perceived by the patient, as well as any information related to the reason for the consultation.
Medication and treatments: the anamnesis also includes the treatments and medications prescribed to the patient, as well as their subsequent reaction.
Antecedents: in the antecedents we compiled both the previous pathologies of the patient, as well as medical antecedents related to relatives that could be of interest for future diagnoses.
These four sections are essential in any clinical profile, but we can add any type of information that may be of interest to the healthcare provider.
The anamnesis is a fundamental principle for the diagnosis of diseases in patients.
The clinical interview includes four essential phases to obtain the necessary information.
Reception: the initial contact is also important in terms of the trust perceived by the patient.
Development: the patient must feel comfortable throughout the entire interview, while we record their reactions and answers.
Closing: the history and consultation culminate CRB Directory in a conclusion and the next phases of treatment.
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 content.
Digitized anamnesis establish a series of conditions when granting permissions, therefore they are safer and comply with the laws that regulate data protection, provided they have an adequate storage medium.
