ANAMNESIS AND ADDITIONS TO ANAMNESIS

Past medical history, family history and other significant information should be noted in this part: the patient’s present and suffered diseases, past surgery, family history and allergic reactions, risk factors present (smoking, excessive alcohol consumption. substance abuse, insufficient physical activity, dyslipidemia, psychoemotional stressors, etc), professional anamnesis (workplace, occupational hazards), and brief information about “major” disease (since when patient considers he has had the disease, its possible causes, frequency of exacerbations and precipitating factors, treatment and it’s effectiveness, frequency of hospitalizations, frequency of sanatorium and resort treatment, weather the patient is under dispensary surveillance and since when).

This part is filled in and signed by a physician specifying the date of taking the anamnesis.

Additions to the anamnesis are filled if new data emerges over time and and in case of newly discovered circumstances (allergic reactions, change in working and living conditions, etc). It is mandatory to indicate the date the additions were made.

PHYSICIAN’S RECORDS

The number of sheets for writing down physician’s records (so-called diaries) differs from patient to patient and depends on the frequency of patient’s visits, duration of each case of disease, etc.

The structure of the physician’s record assumes specifying the date of patient’s visit (day, month, year), name of specialty of physician performing examination, type of examination (home visit, ambulatory), primary or repeated (follow-up), description of patient’s complaints, first – major complaints, then – other complaints (particularly significant symptoms are detailed precisely), duration of disease, its association with any factors, treatment and its effectiveness (non-drug treatments, procedures including surgical, medications, complimentary and alternative medicine treatments, etc).

Physical examination is performed in accordance with the propedeutics of internal diseases scheme, but in busy outpatient settings results of examination are written down in brief (but the examination itself is done thoroughly!).

In this section write down the results of physical examination; comment on ecery organ system with thorough and detailed description of findings in those organs and systems that are relevant to diagnosis; always list vitals: assess level of consciousness (whether patient appears alert, oriented and cooperative), body temperature, heart rate (HR) and pulse, blood pressure (BP), respiratory rate (RR), if possible – pulsoxymetry (SpO2). Also indicate height, weight, waist circumference. Noting the fact of smoking, excessive alcohol consumption and drug abuse here (though already noted in anamnesis) is not a mistake.

Diagnosis is formulated in accordance with current classifications and is based on anamnesis (careful history taking, etc) and physical examination.

Patient management is specified: plan of laboratory and diagnostic tests if required, diet recommendations, regime (e.g. bed rest), medications (dosage, regimen) and non-medication treatment (rehabilitation, physiotherapy, complementary and alternative treatments, etc), hospital or specialist referral, etc.

If issuing a temporary disability document is necessary, indicate it’s batch, the exact date of issue, and the exact date of the next visit (during which the document and term (duration) of temporary disability might be prolonged or terminated (closed), this is also noted) in the end of the record. Physician’s record is confirmed by physician’s signature.

Date: 2016-04-22; view: 1034