This document discusses electronic medical records (EMRs) and electronic health records (EHRs). EMRs contain patient medical data entered by doctors, while EHRs also include additional information like demographics and test results. EMRs are part of EHRs and are used for registration, billing, screenings, and scheduling. EHRs provide benefits like comprehensive patient histories and improved care, but also risks like security issues, hacking vulnerabilities, and data loss. Taking an accurate patient history is important for determining the cause of illness, and involves listening carefully and asking common sense questions. History taking is both an art and a science, requiring social and medical skills to build patient confidence and direct objective principles for maximum benefit.

1. PATIENT RECORDS
DR. GOUTHAM VALAPALA
MD (GENERAL MEDICINE),PGDIP.DIAB,FICCM,MBA(HOSPITAL MANAGEMENT),FIME
ASSOCIATE PROFESSOR
DEPARTMENT OF GENERAL MEDICINE

2. WHAT IS AN EMR AND HOW IS IT USED IN HEALTHCARE? EMR VS EHR
• Electronic medical records (EMRs) and electronic health
records (EHRs) are often used interchangeably.
• An EMR allows the electronic entry, storage, and
maintenance of digital medical data. EHR contains the
patient's records from doctors and includes
demographics, test results, medical history, history of
present illness (HPI), and medications. EMRs are part of
EHRs and contain the following:
• Patient registration, billing, preventive screenings, or
checkups
• Patient appointment and scheduling
• Tracking patient data over time
• Monitoring and improving overall quality of care

3. SOME BENEFITS OF USING ELECTRONIC MEDICAL RECORDS
AND ELECTRONIC HEALTH RECORDS ARE:
• Comprehensive patient-history records
• Makes patient data shareable
• Improved quality of care
• Convenience and efficiency

4. SOME RISKS OF USING ELECTRONIC MEDICAL RECORDS / ELECTRONIC HEALTH
RECORDS ARE:
• The risks to EHRs relate primarily to a range of factors that
include user-related issues, financial issues and design flaws
that create barriers to using them as an effective tool to deliver
healthcare services. EMR is also a top target in healthcare
breaches.
• Additional risks are as follows:
• Security or privacy issues
• Potentially vulnerable to hacking
• Data can be lost or destroyed
• Inaccurate paper-to-computer transmission
• Cause of treatment error

6. IMPORTANCE OF HISTORY TAKING
• Obtaining an accurate history is the critical first step
in determining the etiology of a patient's illness.
• Many studies suggest that in a large percentage
(70%) of the time, you will actually be able make a
diagnosis based on the history alone.

7. How to take a history???
• You are already in possession of the tools
that will enable you to obtain a good
history.
• An ability to listen and ask common-sense
questions that help define the nature of a
particular problem

8. IS HISTORY TAKING REALLY AN
ART?

9. - History taking is an art, which forms a vital part in
approaching the patient’s problem, and arriving at a
diagnosis.
- Our first moments with the patient are packed with
auditory and tactile information that determines the
effectiveness and the cost of subsequent care.
- The quality of interaction is very important.

10. • Meaningful encounter between the clinician and the patient
involves far more than a rigid question answer session.
• The patient has to feel confidence in the doctor. The doctor has to
use his social and scientific skills both in an intelligent manner.
• This blend of art and science the right proportion brings out the
best results.
• They have to direct their objective principles of medical science
in an artistic manner for the maximum benefit of the patient.

11. GENERAL APPROACH
• Introduce yourself.
• Greet patient appropriately in a friendly relaxed way.
• Confidentiality and respect his or her privacy.
• Try to see things from patient point of view.
• Understand patient underneath mental status, anxiety,
irritation or depression. Always exhibit neutral position.
• Listening ,Questioning: simple/clear/avoid medical terms,
leading, interrupting, direct questions and summarizing.

12. TAKING THE HISTORY
• Always record personal details: -name, age, address,sex,
ethnicity,occupation,religion,marital status.
• Record date of examination and source of history
• Presenting Complaints or Chief complaints in chronological order
• History of present illness
• Past medical history
Systematic enquiry
• Family history
• Drug history

13. • After having obtained the details, the patient should
be approached as follows:
i. Greet the patient, preferably by his name and start
off the consultation with some general questions such
as,
What brings your here?
How can I help you?
What seems to be the problem?

14. • Chief Complaint : The main reason push the pt. to seek
for visiting a doctor or for help.
• Usually a single symptoms, occasionally more than
one complaints eg: chest pain, palpitation, shortness
of breath, ankle swelling etc.
• The patient describe the problem in their own words.
It should be recorded in pt’s own words.

15. History of present illness:
• The doctor may, however, interrupt the patient to ask for the
presence of ‘positive’ or ‘negative’ symptoms pertaining to
patient’s current problems.
• In analysis of the symptoms, it is important to consider the mode
of onset of the illness (acute, subacute, or insidious) and the
progression of the illness to the present state (gradually
deteriorating, getting better, remaining the same or having
remissions and exacerbations).
• A review of all the systems can be made by questioning the patient
patient on the presence or absence of symptoms pertaining to a
particular system.

16. Pain (OPQRST)
• Position/site Severity – how it affects daily work/physical activities. Wakes him up
at night, cannot sleep/do any work.
• Relationship to anything or other bodily function/position.
• Radiation: where moved to Relieving or aggravating factors – any activities or
position
• Quality, nature, character – burning sharp, stabbing, crushing; also explain depth of
pain – superficial or deep.
• Timing – mode of onset (abrupt or gradual), progression (continuous or
intermittent – if intermittent ask frequency and nature.)
• Treatment received or/and outcome.
• Onset of disease Are there any associated symptoms?

17. • History of Present Illness :
• Tips
• - Elaborate on the chief complaint in detail.
- Ask relevant associated symptoms.
- Have differential diagnosis in mind.
- Lead the conversation and thoughts.
- Decide and weight the importance of minor
complaints.

18. • History of Present Illness :
• Tips - Avoid medical terminology and make use of a
descriptive language that is familiar to them.
- Describe each symptom in chronological order.

21. History of previous illnesses:
This should include all important previous illnesses,
operations, or injuries that the patient might have
suffered from birth onwards.
• It is always wise to be cautious while accepting
readymade diagnosis from the patient like ‘Typhoid
fever’, ‘Malaria’, etc. unless the patient has records of
the mentioned illness.
• Tactful enquiry

22. Family history:
• Enquire about the presence of consanguinity in the
patient’s parents
• It is prudent to record the state of health, important
illnesses, the cause and age of death in any member of
the patient’s family
• Presence of a hereditary disorder prevalent in the family
should be enquired for.
• Marital status of the patient and the number of children
that the patient has should also be enquired for.

23. Treatment history:
• This should include all previous medical and surgical
treatment and also any medication that the patient may
be continuing to take to the present date.
• It is important to find out if the patient had been
allergic or had experienced any untoward reactions to
any medication
• Knowledge of any current therapy that the patient may
be on is necessary in order to avoid adverse drug
reactions, when new drugs are introduced by the
consulting doctor.

24. Social history:
• Enquire about the patient’s family life style, daily habits,
and diet;
• about the nature of the patient’s work (hard work or
sedentary),
• about the use of alcohol (number of days in a week and
also the quantity consumed each day), tobacco (whether
chewed or smoked) and betel nut.
• An alcoholic consumes alcohol almost everyday and
develops withdrawal symptoms on abstaining from alcohol.

25. SOAP
• Subjective: how patient feels/thinks about him. How does he look.
Includes general appearance/condition of patient.
• Objective – relevant points of patient complaints/vital
signs,physical examination/daily weight,fluid
balance,diet/laboratory investigation and interpretation.
• Assessment – address each active problem after making a problem
list. Make differential diagnosis.
• Plan – about management, treatment, further investigation, follow
up and rehabilitation.

26. • Graphic chart of temperature, pulse respiration, blood pressure,
number of bowel evacuations, volume of fluid intake and output.
• Orders for treatment written by the physician.
• Reports of laboratory findings and special examinations.
• Reports of anesthesia, operation, physical therapy, occupational
therapy,
• social service, any special treatment.
• Statistical and social data.
• Nurses notes.

27. • Therapeutic measures carried out by various members of health
team.
• Measures ordered by the physician and carried out be nursing
personnel.
• Nursing measures which are not ordered by the physician but
which the
• nurse carries out to meet the specific needs of a patient/client.
• Behaviour and other observations of the patient which are
considered to be pertinent to his/her general health.
• Specific responses of the patient to therapy and care.

28. • Patient's/client's records are unquestionably a valuable
documents. These should be made on paper of good
quality and protected from soiling, and burning.
• These must be preserved in a special file and kept in a
special rack on wheel or hung in a chart room near the
head nurse's station.
• These records must not be handled by patient's relatives
and non-medical personnel. The recording should be
done with care to prevent waterdrops falling on the
records. All records of the patient/client be sent to
medical record section after the discharge.

29. COMMON MISTAKES

30. OSLER ONCE SAID,
“LISTEN TO THE PATIENT-HE
MIGHT BE TELLING YOU THE
DIAGNOSIS”
• When we learn to do so, we become artists of the best kind.

31. THANK YOU