A comprehensive medical record demonstrates: complete care, fills the gaps in data, and provides evidence against allegations. Such a record requires a systematically arranged set of open-ended questions accompanied by active listening. Each patient has a distinct version of a loosely organized aggregate of information related to their particular illness. When this information is put together in a systematic and organized method, a detailed and complete outlook of their disease is obtained. The result is a comprehensive and focused medical record.
Clinical data points that shouldn’t be missed
- Systemic and Physical findings
- Radiology/imaging results
- Laboratory investigations
- Past medical history
- Discharge summary
- Progress notes
- Referral letters
- Current medications
- Outpatient notes
How Arintra helps?
Arintra understands that a scrupulous and complete history-documentation can work wonders in eliciting a patient’s story and in improvising patient care.
“For every minute spent in organizing, an hour is earned”
Supported by an organized data collection format; it ensures that the best patient clinical records are generated which:
- Assures patient care continuity
- Improves auditing
- Enhances informed decision making
- Allows communication of relevant patient information among physicians
- Increases the time available for patient care
- Reduces physician information-documentation hassles
- Reduces patient expenditure on repeated appointments.
Arintra uses a questionnaire-based format interview sheet that contains multiple-choice questions about common symptoms. This health history taking tool has been structured to organize patient information in such a way that focuses your attention on the most specific information. Such a format enables easy and quick clinical reasoning.
A typical Arintra profile includes the following:
- Chief complaints
- A detailed history of presenting illness
- Drug Allergies
- Family History
- Social History
- Medical History
- Surgical History
- Lab investigations
- Medication History
With a history-taking tool like Arintra, there needn’t be any worry about losing patient information again because
- It organizes patient history right from its inception
- In case any information has been overlooked, the review of systems ensures that it’s documented
- Since a greater bulk of documentation has been documented pre-consultation, any bit of information which could have been disregarded during the documentation process can be recorded during the consultation.
Thus, Arintra makes sure patient-history has been triple-checked before it is recorded.