Medical Records

Medical Records - are essentially the facts about patient's current medical conditions. The items for Medical Records are: Parameters (Symptoms and Research results parameters), Investigations, Diagnoses. The investigations in the medical records are those, which have already been completed, not those, which are suggested. The diagnoses in the medical records are those, which have already been made to the patient before, not those, which system is thinking about.

Note, there is a some difference between the ordinal meaning of the term Medical Records and the way how this system treats them. Normally doctors or hospitals would keep their medical records for years and accumulate all medical facts about the patient, which had come to their knowledge on any occasion. And no doubt this information is very useful for many purposes.
But this system expects Medical Records to have only fresh and up to date information about the patient's current conditions. In other words only information relevant to the current diagnostic process should be stored there.
For example, WBC, Hemoglobin, Blood sugar level measured 2 years ago (when patient even was not sick) may only confuse the system and lead to the wrong diagnosis. This is because the system will treat those data as if they were current. The same applies to Investigations. For example, if EKG was done years ago it should not be entered into medical records because it would prevent the system from suggesting to do EKG, which otherwise may be offered for any heart condition.

There is no strict and common rule about what is old and what is fresh. The relevance and freshness of certain fact or information should be determined by doctor applying his/her medical judgement. For example, the fact that the patient had fits and seizures 3 years ago may be still relevant while diagnosing the epilepsy. Or 5 years spinal injuries may be relevant for any diagnosing of any nervous disorder. But 3 years old blood tests or urine tests definitely will not work.

There may be cases as well when doctor deliberately wants to know old medical records for the patient. For example, it is common for cardiologists to check 2-3 years old EKG and compare it with the current EKG to see how the patient's condition progresses. This situation also can be easily managed by the system. In this case you need to introduce 2 separate research parameters, for example "Old EKG results" and "Current EKG results". The corresponding Rules of logic should in this case explicitly refer to either Old EKG or Current EKG or both of them.

Medical Records in this system are managed by Medical Records form.

See also: Medical Records form, Parameter, Diagnosis, Investigation.