Past medical history includes past health status and past diseases. Past history, also known as past medical history, means that doctors ask patients about their past health status and past diseases when they ask them for medical treatment. Past health conditions include eating habits. The usual health status of patients may be related to their current diseases, so it has important reference value for analyzing and judging the current diseases.
Past medical history includes surgical history, preventive injection history, allergic history and systematic review. Some diseases that patients suffered in the past may be closely related to the current disease syndrome. Although the symptoms disappeared after treatment, they were not carved by the roots.
Medical record is a record of the occurrence, development, outcome, examination, diagnosis and treatment of patients' diseases. It is a patient's medical and health record written according to the prescribed format and requirements by summarizing, sorting and comprehensively analyzing the collected data.
A brief history of medical record development:
6th century BC, ancient Greece. Through patients praying for treatment by idolatry, the priests in the temple recorded the condition, symptoms and treatment results of each patient and kept them as personal medical records. In the 5th century BC, Hippocrates advocated that medical records should achieve two purposes: reflecting the disease process and pointing out the possible causes of the disease; The emphasis is on the description of the disease.
/kloc-At the beginning of the 9th century, with the invention of stethoscope and the development of other medical devices, doctors' senses have been expanded, and medical records have also expanded from the narration of patients or their families to the discovery of doctors and nurses. In 1960s, Weed improved the structure of medical records, and he proposed the problem-centered medical record structure SOAP.
Baidu Encyclopedia-Past History