Arintra follows a structured format to organize data whereby even the most basic information is addressed and given importance. With this, typical errors that may be encountered in a handwritten clinical history are resolved.
Every time an entry is made, it automatically saves the date and time of visit. This allows for future reference of patient history and ensures continuity in care. It also generates a unique identification number for every patient that makes a new visit. With the help of the unique identification number given to a patient, Arintra helps reproduce any health information that pertains to that patient during future visits.
Purpose of visit:
This is an essential part of any history-taking because it holds clues to why the patient has arrived and thereby collects the type-of-visit tailored history. New admission patients may require a detailed and comprehensive history. Patients seeking care for a specific concern might require a more problem-oriented or focused history. Patients who make regular visits for health-maintenance may prefer to discuss specific concerns or update their previous investigations.
Basic Profile Information:
This stores the age, gender, name, height, and weight of the patient. Subsequently, patient vitals like the temperature, pulse, oxygen saturation level, random blood sugar and respiratory rate is recorded.
Any metabolic risk factors like diabetes, hypertension, asthma, thyroid disorder or lifestyle risk factors like smoking, alcohol consumption, tobacco chewing, sleeping difficulty, etc. are interrogated and recorded. These are often correlated with presenting illness.
This component of a clinical history could be the earliest predictor of any illness. It is customarily the first information obtained from any patient and assists physicians to make a prognosis of the disease. The chief complaints are further supported by the history of presenting illness. The present illness reveals how the patient perceives their symptoms and what effect it has had on their life.
Patients may have more than one symptom and each symptom requires its own particularised assessment. Arintra offers a list of suggestions related to the indexed term when the patient chief complaints are entered. This is followed by a detailed and chronological review of the symptom onset, nature-of-onset, the circumstances which make it better or worse, and any other additional details. Each symptom is then assessed in detail through accordant queries.
Normal lab results can be just as valuable as abnormal lab results to separate potential causative factors from the actual causative factors. For example, a normal TSH level in a patient complaining of hair loss and a normal ECG in a patient indicating chest pain. Such laboratory investigations direct the physician towards a differential diagnosis. Whenever a lab parameter is entered, Arintra offers prompts from which the intended parameter can be selected. Subsequently, the lab value and its date of assessment can be entered. A checklist that confirms whether or not the value is within the normal range is produced.
Review of systems:
This feature uncovers problems that the patient may have overlooked. It contains a series of checklists from head-to-toe. Although it may seem needless, it ensures that nothing has been missed. For all practical purposes, this opens a slot to double-check before closing the collection of history.
Elements contained in medical history provide a baseline for identification of drug-related problems. It is broken down into subclasses: medication-related history, conditions history, past procedures, allergies, family history and occupational history.
A good medication history contains
- Recently prescribed medications
- Currently prescribed medications
- Previous adverse drug reactions or hypersensitivity reactions
- Over-the-counter drugs, herbal remedies, vitamin supplements
- Adherence to therapy
This provides a list of past and current medical conditions.
It includes past surgical history, hospitalization history, obstetrics history, etc.
Information related to allergies provides knowledge on allergic reactions the patient may have had to any medications or foods.
This outlines any chronic illness traits that could have been inherited from family and relatives.
Sometimes work environments can cause certain medical conditions. It is imperative to collect the work history of a patient before drawing any conclusions on the diagnosis.
On the grounds that such detailed documentation is done pre-consultation, physicians will be able to make a better diagnosis.