Example of Clinical File

Science / by admin / July 04, 2021

A clinical recordIt is a document in which all the data collected by a patient are gathered; These data are placed in an orderly and accessible way, so that doctors and officials can carry out the necessary or corresponding procedures.

It has no official validity, and its creation and use is generally for the doctor's use and only complements the clinical history that does have official validity.

The parts that said file can or should have are:

Name of patient
Name of the doctor
Name of the assistant or nurse (optional)
Name or type of disease
Type of treatment
Patient's age
Patient gender
Patient height
Blood type
Applied studies
Medical interview (optional)

Example of clinical record:

Hospital "Médica Patria"

Cedula Prof. 4569878

Date: November 07, 2012

Folio 6589

Patient's data:

File No: 563

Name of patient: Felipe González Cárdenas.
Patient's date of birth: August 1, 1974
Sex: Feminine
Medical reason or circumstance: Pregnancy
Period of pregnancy: 25 weeks
Identification document: Identity card

Clinic data:

Hospital "medica patria" S.C.

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Direction: Colorado Avenue No. 789 Col. Royal, municipality of Coacalco de Contreras México C.P 56874.
Tel. 5684XXXX
Section: Maternity:
Responsible: Dr. José Flores Tapia, Surgeon and obstetrician

Clinical data

Beginning of symptoms: October 24, 2012
Internment: November 6, 2012
Pathology (Background): Intermittent pain in the muscles of the body.
Clinic: Diabetic Neuropathy

Laboratory studies

Ultrasound did not give results that show any damage. Blood Clinic: shows a high level of Sugar: Urine Study: reveals a urinary infection Medical Interview The patient feels sudden pains throughout the body, they are throbbing and repetitive pains, they come to him suddenly without cause apparent; He declares that he suffers from diabetes and does not know what room he is in. It is clear from the interview that the patient has not cared for his illness adequately.

He does not have leg ulcers but his feet are severely swollen, his mobility is limited. He apparently has problems feeding due to ignorance of the same disease, and it is recommended that he be admitted to be under observation.

Doctor in charge of the department:

Dr. Javier Valverde Otero
Firm

Assigned Physician:

Dr. José Flores Tapia
Firm

If you need an example request your file.

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