Question

Discuss why and how taking a detailed medical history of the patient is important to the medical evaluation. How does an electronic health record (EHR) help with this process?

Answer 1

The assessment part of medical record of patient consist of history taking including patient's medical history and surgical history. A detailed medical history provides information about patient's existing illness, diseases that occured in the past, drug history, allergy history. Every information have its own importance in the diagnisis and treatment of the patient. For example: the history of presence of any diseases in the past while help to trace the underlying cause of an existing problem like patient with retionopathy have a history of diabetes. So treatment of the underlying cause will improve the present complaints. Another example is drug and allergy history. This information helps the physician to decide which medications can be prescribed and that is safe for the patient. It will prevent patient harm due to overdosage of drug and also life threathening hypersensitive reactions. The allergy history is more important while performing diagnostic procedure with use of contrast like CT scan with contrast.

The medical history frames a platform for further planning and implementation of interventions to treat the patient. A correct medical history will help physician to diagnose the patient correctly and thus it will result in a positive outcome. The medical history also serves to help in medical evaluation of patient as it helps in developing accurate medical and nursing diagnosis of patient based on which the imterventions are planned.

An electronic health record helps to document the received data during assessment correctly and clearly. This data stored in EHR is easily accessible for patient and the healthcare professionals. The assessment dat i.e the medical history is recorded in a systematic format that is comprehensive and simple to understand.Moreover, its stored safely so that the confidentiality and privacy of the data is maintained. It also helps in easily handling of the records and saves effort and time.