CLINICAL HISTORY

The recording of the information obtained, in the doctor-patient interview, through the
interrogatory, the physical exam, and the results of the clinical laboratory studies, as well as those
of diagnostic imaging, is known as a Clinical History. It collects the information necessary for the
complete care of the patients. The recording of the information obtained in the interview includes
medical indications, daily evolution, nursing notes and the Epicrisis or final note. (in the
Institutional Chart)

The record of the CH builds a main document in a health information system, essential in its
healthcare, administrative aspect, and constitutes the complete record of the care provided to the
patient during their illness, from which its significance as a document is derived legal. In other
words, by registering it, builds a document with legal validity (that is, before the courts). If it is not
registered, it is an undocumented medical history (without legal validity, only testimonial)

It serves to register the Clinical Method (Methodological order of evaluation of a patient). F

The CH or clinical record constitutes a valid legal medical document, which contains information
covering the patient's healthcare, preventive, and social aspects.

It is the basic record or database that contains the information of the doctor's work.

It fulfills various purposes. The collection of data, which when ordered helps to build knowledge
about the patient, to guide the diagnosis of problems, to reason and establish a line of studies and
diagnostic and therapeutic procedures. It is an essential instrument for intercommunication
between the members of the health team, for the comparison and successive verification with the
information that is being incorporated, to obtain statistical studies, carry out research and autopsy
confrontation.

The CH is opened for new information and always originates with the first episode of health or
disease control in which the patient is treated, either in the public or private hospital, the
Assistance Center or in a Medical Office.

As of today, the patient has as many stories as there are institutions where he consults. With the
advancement of data recording methods, it is not difficult to imagine, soon, that information will
be kept in a single database with universal access.

The Record of the CH builds a main document in the hospital information system, essential in its
healthcare, administrative aspect, and constitutes the complete record of the care provided to the
patient during his illness, from which its significance is derived as a legal document.

The CH is part of the science of Clinical Semiology. It must be true, complete, understandable, and
coherent and follow an order or regulation that makes the common language of doctors.

With experience, a more specific CH can be developed, but never incomplete. There is no lack of
data, which, although negative, have a clinical hierarchy. It must be transcribed in logical order,
without inducing, crossing out without clarifying, or blotting in the writing in the description of the
data, especially since it is an instrument with legal value.

Time is short in outpatient consultation and is sometimes a natural enemy of thoroughness in data
collection. When making the history with the inpatient, the available time is greater. In some
healthcare facilities, a pre-printed form is used, which must be completed by the patient before
the medical consultation. This subtracts necessary human contact from the doctor-patient
relationship.

The suggested order to carry out the complete CH (clinical method) in hospitalization, which is
oriented to build a list of problems is:

Basic information: Interrogation, Physical exam, Clinical Laboratory, Diagnostic Imaging, Special
studies

List of Problems:

• Diagnostic discussion, evaluation plan and patient education for each of the problems
• Evolution Notes
• Medical indications
• Nursing Notes and Charts
• Epicrisis or note of externalization

INTERROGATORY OR ANAMNESIS
The interrogation or anamnesis is the first step in the preparation of the clinical history. It is one of
the most important skills available to the doctor and can very often provide the data (Subjective or
Objective, Symptoms or Signs) that define the clinical picture.

It can be done to the patient who consults or to an observer who is a witness to his illness, such as
a family member, neighbor, or occasional witness. The content must be comprehensive, including
the reasons for the consultation, both in the body and in the mind. All significant events in his
health, in the Bio-Psycho-Social aspects, of his life are ranked.

It usually begins by letting the person spontaneously state their reasons for consultation, with only
interruptions to avoid dissociations or the loss of the thread of thought. It is extremely important
to know how to listen, allowing oneself to intervene only when clarity can be provided, to what
the patient narrates.

The facial expression of this, his tone of voice and the way of speaking, his attitude, are giving keys
to guide the diagnosis and to detect the meaning and importance of the symptoms. By listening,
one learns not only about the disease, but also about the sick.
While the information is being obtained, the voice, language, intellectual level, expressive
capacity, etc. will be evaluated.

As the interrogation develops, the dialogue should be noted, in a prudent way, so as not to
demonstrate loss of attention. Attitudes such as frequently looking at the clock, or repeating
questions already asked should be avoided. This behavior transmits security and limits the anxiety
of the consultation.

After a reasonable time, letting the person speak, the doctor will initiate the directed questioning,
which should not be induced, but clearly objective. This way of questioning is guiding the problems
posed by the patient and their possible causes (diagnoses).

During it, different diagnostic hypotheses originate and accept or reject, which will later be
confirmed or discarded in the subsequent study of the patient (inductive-deductive). This
evaluation of the patient will depend to a great extent on the information obtained in the
interrogation.

In the registry it is necessary to maintain a logical order of the narration, trying to group the
different symptoms and signs such as syndromes and problems that must then be followed and
solved.

The objective of the clinical method is the etiological diagnosis (I know), but the starting point is an
isolated fact. These isolated data (Symptoms and Signs) or problems should be questioned to
obtain, from them, as much information as possible, such as place and form of origin, intensity,
time of appearance, variations with physiological phenomena (breathing, digestive, muscular
movements, etc. etc.) One by one the data must be questioned in detail. The anamnesis contains
50% of the keys to reach the diagnosis.

If the questioning is taken chronologically, recent episodes should be ranked and receive the most
attention. If the problem history medical guidance system is used, those problems that are
dominant should be considered first.

The doctor learns, through experience, to know the difficulties that arise, by doing a good
questioning, and it is here where the knowledge, practice, and skill of the professional are most
clearly manifested. Likewise, the capacity for synthesis, which is acquired with practice time, gives
an advantage to the experience. On the other hand, the interrogation, the initial part of the
medical interview, and the opening of the medical history, constitutes the fundamental means to
begin and expand the relationship with the patient, gain trust and obtain his collaboration.

It is necessary from the beginning of the dialogue to separate the acute reasons for consultation,
which must be resolved relatively quickly, from the chronic ones, which require a calmer order for
their control and follow-up, and from health controls , which have their organized scheme of
medical intervention, that is, there is a different medical intervention in each case.