Various Types Of Clinical Documentation

We know that clinical documentation is very important and should be implemented by all hospitals. Before one begins the process of documentation it is important to know what the various kinds of documentation there is. The following article lists out the different kinds of documentation that is used.
Clinical Documentation could start right from the time a patient reports for clinical examination either for a routine check up or with any specific ailment. The information contained in the documentation, also called the health record, would contain the following details.
• Name, sex, date of birth, residential address and emergency contact telephone number
• Blood type
• Dates of last physical check up and dates and results of previously done tests and screenings
• Brief details of major illnesses. Details of surgeries performed with dates
• Allergies, if any
• List of medicines prescribed and duration of their use
• History of family illnesses
• Chronic diseases if any
• History of any trauma or accident or any unusual symptoms affecting a person's health
Clinical documentation details complete information of the state of health of a person since birth. It records major and minor illnesses and also growth landmark. It often gives a clue to the present diseases of a person; following details included in the history would make this point clear.
• Surgery history - it would contain operative reports and details of any surgery performed.
• Obstetrics history - would give history of past pregnancies and any clinical findings for them.
Medicinal or food allergies -
• Family history - health status of near relations, common diseases in the family
• Social history - patient's behavior during a major illness and occupation
• Habits - addiction if any, physical habits, exercise and diet and also sexual habits
• History of immunization
• Developmental history - this is important for children and teenagers. Many social stresses, economic factors and diseases affect growth. Developmental history records such cases.
As part of clinical documentation, results of individual checkups by a physician or assistant physician or a nurse are recorded. Clinical documentation, in case of hospital admission or consultation by a medical specialist, could be exhaustive. Shorter forms may be necessary to record observations in a routine visit.
Details in clinical documentation in such cases could contain:
• Present illness history
• Physical examination including body temperature, respiratory rate, blood pressure, heartbeat, muscle power, urine output, etc
• Diagnosis of present illness
• Prescriptions and instructions to other health team members
When a patient is hospitalized, all test results like blood and urine test and all special tests are recorded. Radiological examinations, pathological tests, endoscopy, CT scans, etc are included. All these form a part of clinical documentation. Documentation plays a very important role as it contains the entire medical history of a patient. It provides invaluable insight into a person's condition and helps in simplifying treatment.