Albert Science International Organization

ARTICLE DESCRIPTION: 

Abdul Kader Mohiuddin, PATIENT HISTORY & MEDICAL RECORD: PROPER SOLUTION FROM ACCURATE PROBLEM IDENTIFICATION, ASIO Journal of Medical & Health Sciences Research (ASIO-JMHSR), 2019, 3(1): 13-17.

DOI Link :: http://doi-ds.org/doilink/10.2016-74831794/; DOI Link :: http://doi-ds.org/doilink/08.2019-56653548/

ABSTRACT:

Clinical record keeping is a fundamental part of great expert practice and the conveyance of value healthcare. Despite the type of the records (for example electronic or paper), great clinical record-keeping should empower coherence of consideration and should improve the correspondence between various healthcare experts. Medication histories have generally been reported in the 'Medication history' area of a specialist's clerking; if pharmacists recognized any blunders with this rundown, they would more often than not record these in the ensuing advancement notes. Medication histories are significant in forestalling remedy mistakes and subsequent dangers to patients. Aside from avoiding remedy blunders, precise medication histories are likewise helpful in identifying drug-related pathology or changes in clinical signs that might be the aftereffect of medication treatment. A decent medication history ought to incorporate all presently and as of late endorsed drugs, past ADRs including hypersensitivity reactions, any OTC medications, including herbal or alternative medicines, and adherence to treatment.

Keywords: Medical Record, Medication History, Medication Discrepancy, Medication Error, Transition of care.

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