Question

what are your thoughts on leaving out pertinent information from a patient's chart? How would that decision impact your patient's care?

Answer 1

Every information of patient chart / patient medical record is very much important. Let us first have a look at what are all the sections of patient medical record.

1. Personal information such as name, age , address, contact details, occupation

2. Medical history such as past medical history and present medical history , any treatment course undergone in the past

3. Family medical history such as hereditary disease etc

4. Medication history which includes any practices of ayurveda, OTC etc

5. Lifestyle and personal habits which includes smoking, drinking, drug addiction etc.

These are all the main components which are present in the patients medical history. If personal details are missed out then the treatment according to the age cannot be given. If medical history such as past , and present is not collected properly then we will no know if patient had any drug allergy, or any medicines that he is following currently because current treatment may react with existing medication course. Family history such as hereditary history is also very much important because risk factors for the patient must be analysed for example diabetes, hypertension, cancer etc, cancer Genes can be detected by properly collecting family history.

Hence all these are very much important..