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What Does a Patient Chart Look Like?

A patient medical chart holds all the important and relevant information that a doctor may need to give the correct diagnosis to a patient. Essentially, it is a description of the big picture, where when certain symptoms appear, and the patient’s medical history is detailed, which may give an explanation of why.

Writing, and keeping all this information can be time-consuming for a physician. This is why it is not uncommon for them to seek the help of a medical scribe, who will do this task for them, so the doctor can focus on giving all of their attention to the patient instead.

This is just one way in which technology has streamlined the healthcare industry in the last two decades, taking a much-needed lift off of healthcare professionals’ backs. 

In the following segment, we will discuss what sort of information a patient chart contains.

Demographics

The patient’s demographic is important because certain races, as well as the patient’s gender, may make them genetically predisposed to be more susceptible to certain medical conditions. Additionally, knowing the patient’s age can help determine appropriate screening and treatment options based on guidelines for that specific age group.

Medications

The physician needs to know what medication the patient is taking or has taken in the past. If the patient cannot tolerate a certain type of medicine, for example, Ibuprofen, which may make their stomach upset, the doctor may look for medicinal alternatives.

Also, some medications cannot be taken together, as they could be potentially dangerous. A doctor will never prescribe opioids to somebody who is taking benzodiazepines or nitrates to somebody who is taking PDE-5 inhibitors.

Allergies

Allergies are important to keep track of because a patient needing antibiotics, may be allergic to penicillin and thus require a different type of antibiotic, such as erythromycin, azithromycin, or cephalosporins.

Family History

Knowing the patient’s family history is crucial, as some diseases are hereditary. Patients who have family members suffering from diabetes are more likely to suffer from the same condition. It gives the physician more information and, therefore, enables them to make critical diagnoses earlier than they would without this knowledge.

Medical History

Knowing what sort of procedures the patient has gone through before, as well as when the last time they saw a doctor was, is essential information for a physician. This information can help the physician determine if the patient has any underlying conditions that may affect their current symptoms.

Additionally, it can also help the physician avoid prescribing medications that may interact negatively with previous treatments.

Vaccines

The doctor can rule out certain diseases if the patient has received their vaccination for them. For example, somebody who is vaccinated for chickenpox is less likely to get this disease, and if they do, their symptoms will not be as severe as for somebody who is unvaccinated.

Lifestyle

If the patient is a heavy smoker or consumes alcohol regularly, and in large quantities, the physician needs to be informed about it, as this information can help the physician understand potential risk factors for certain conditions. Additionally, lifestyle habits can impact the effectiveness of certain treatments and medications prescribed by the physician.

History of Surgeries

Doctors can rule out certain conditions based on the patient’s history of surgeries. If the patient has stomach pain but has had their appendix removed, the physician will know that they are not suffering from appendicitis.

Final Words

A patient chart is necessary for a general practitioner to provide the best diagnosis possible. There are many different things that the chart documents. By having a complete patient chart, physicians can better understand the patient’s overall health and provide appropriate care. 

Last Updated on May 15, 2024