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Medical Histoty and Medical Records

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Medical history is a long record of what has occurred to the patient after birth. It accounts for diseases, minor and major sicknesses as well as growth reports. It provides the practitioner with an idea about what occurred to the patient in the past. As such, it may frequently provide hints to recent sickness states. Following are the subsets included in it. Surgical History. Surgical history is an account of surgery did for the patient. It consists of operation dates, operative reports or the elaborated story of what surgeon did.

Obstetric History. This lists prior pregnancies and their consequences. It also comprises any ramifications of these pregnancies. Medications and Medical Allergies. The medical record may consist of a brief report of the patient’ s recent and former medicaments and any medical allergies as well. Family History. It lists the health condition of immediate relatives and their reason for death as well. It may also show illness common in the family or found in just one sex or the other. It may also have a pedigree It is a precious asset in determining some consequences for the patient.

Social History. This is an account of human interactions. It describes the kinships of the patient, his vocations and training, school life and religious life. It would be useful for the physician to understand what kinds of community backup the patient might require during a major sickness. It may explicate the conduct of the patient regarding sickness or loss. It may also provide hints regarding the reason for an illness. Habits. Several habits which affect such as drinking, smoking, exercise and diet are recorded as a component of the social history.

This segment may also contain more personal details such as sexual habits and sexual preference. Immunization History. This includes the account of vaccination. Any blood test to determine immunity will also be contained in this section.

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