History is a medical document drawn up on the patient in the hospital and sanatorium treatment. A patient, who is in outpatient treatment, are ambulatory card. In the latter case, the record is more briefly.
History consists of several sections. The first section is a passport statistical part - surname, name, patronymic name, age, occupation of the patient, the name of the medical institution, the procedure of admission, diagnosis of the medical institution that sent the patient, preliminary and final diagnosis the patient and disease outcome; in the case of death-prosthetic and orthopaedic diagnosis.
The second part includes patient complaints, anamnesis of illness and life. The anamnesis of disease - information about the beginning of the disease, its development. In the history of life entered into former diseases, about the state of the closest relatives of the patient, the nature of work, living conditions, diet, and habits of the patient (alcohol, Smoking, systematic use of drugs).
In the third section is entered into examination of the patient at the moment of his admission to the hospital (status praesens). This section ends with a preliminary diagnosis of his brief substantiation made as a result of anamnesis and examination with the help of the main methods of research.
The fourth section (the so-called diary) reflects the dynamics of the disease, the performance of individual constants (body temperature, the properties of the pulse, body weight and other), physiological functions (the amount of urine, frequency and nature of the chair), the results of additional methods of research (laboratory, and instrumental), conducted on the basis of the preliminary diagnosis and follow-up of patients. In this section are written opinions of the consultants and treatment. After a certain period of time (10-14 days) is filled in a landmark report, which should reflect all the changes that happened with the patient over a specified period of time (changes in organs, the effectiveness of treatment, the new assumptions about the diagnosis in connection with occurrence of those or other data).
Upon discharge from hospital are final report, which substantiate the diagnosis, treatment, further forecast and give medical-preventive recommendations. In the case of death after the final epicrisis make the results of pathoanatomical dissection. History signed by the attending physician and head of the Department. In treatment-and-prophylactic establishments of history is stored within the prescribed period.
History is the basic document for further dispensary observation and treatment of the patient after discharge from the hospital, and also for solution of the question about his disability. However, the history can serve as a material for forensic investigation as a legal document.
Usually history is conducted by the doctor. However, the first section of history of the disease, with the exception of pre-and post-diagnosis, fills the average health worker. Nurse conducts the history of their own, if he is temporarily replaces the doctor of the district hospital. On obstetric paragraph paramedic lead outpatient magazine or ambulatory card.