A medical history is a documented profile of a patient’s collective medical data that includes hospitalization, history of illness, medical and surgical procedures, diagnostic data, medications and even allergies. This information helps your physician make accurate diagnosis on a disease process and provide prompt intervention based on a symptom experienced. A review on your medical history when undergoing a procedure such as plastic surgery is especially important to give the surgeon a baseline on the treatment before and after the surgery. If you have any allergies with certain medications that are documented in your medical history chart that may be used during the procedure, your doctor would have to make adjustments if necessary to counter any adverse reactions.
Physicians make documentation and creation of a checklist customary based on the patient’s medical history profile. In the event of an elective surgery, the medical history record is attached to the patient’s chart. The surgeon or the physician would then interview the patient to update and validate the information on the medical history chart. Once the data is gathered and the information is validated, your surgeon or physician would provide medical clearance for you to undergo the procedure.
Just like any other medical document, your medical history record is considered a legal document. All information in the medical history profile is legally supported for non disclosure among healthcare practitioners. Disclosure of such can be a breach of privileged communication between client and physician’s professional relationship. If however, you have an insurance company requiring you to present and submit a copy of your medical history records; it will be your sole discretion to give them the privilege of keeping the document for record purposes.
As part of taking responsibility and involvement in your own medical or surgical treatment, you have to be familiar and aware of your own medical history. Your physician, acting as an advocate would explain your current health status, what the treatment is for, alternatives to treatment (sometimes the most conservative treatment is initially recommended) and the rationale of every disease process on your medical history chart. Cooperation is vital in the process of making an accurate and reliable medical history record and for its profiling. After the profiling, look into your medical history chart and have your surgeon clarify any information entered that may seem unclear to you.
It is also possible to get a personal record of your medical history for reference. Every time you need medical attention or your insurance asks for your medical history chart, you can provide them your copy as a requirement. In the event that you will be getting a plastic surgery abroad (medical tourism), you can provide your doctor or surgeon a copy of your medical history so that less time will be spent on interviewing you on medical history related questions and more time on prompt medical-surgical treatment. It is important for you to remember that no other person besides yourself and your doctor, unless given prior authorization take possession of this document as his own.