ai-medical-chatbot-master/2-Data/tools/Notes.txt

The standard procedure for a Doctor is:
1) Generation of the general clinic history. ( With Anamnesis.)
  
2)  Classification of the health problem.
Depening of the classification of the medicine area.
We can go deeply with an additional custom clinic history.


3)Given the whole description of each patient we should include
the description of the patient, what is asking for.

4)Depending of the situation of the patient with all information individual collected
it is possible give medical diagnosis for a general case.

5)If is needed we can go futher for the special case and
repeat the step 4)







[Patient Information]
- Full Name: [Patient's Full Name]
- Date of Birth: [Patient's Date of Birth]
- Gender: [Patient's Gender]
- Address: [Patient's Address]
- Phone Number: [Patient's Contact Number]

[Chief Complaint]
- [Description of the patient's main reason for seeking medical attention]

[Present Illness]
- [Detailed description of the current illness or symptoms, including their onset, duration, severity, and any relevant factors]

[Medical History]
- Past Medical Conditions:
  - [List any significant medical conditions the patient has had, including dates of diagnosis]
- Surgeries/Procedures:
  - [List any surgeries or medical procedures the patient has undergone, including dates]
- Medications:
  - [List current medications, dosages, and frequency]
- Allergies:
  - [List any allergies the patient has, including medication, food, or environmental allergies]
- Immunizations:
  - [Include information on relevant vaccinations and their dates]

[Family Medical History]
- [List any significant medical conditions that run in the patient's family, such as heart disease, diabetes, cancer, etc.]

[Social History]
- Occupation: [Patient's occupation]
- Tobacco Use: [Specify if the patient smokes or uses tobacco products]
- Alcohol Use: [Specify if the patient consumes alcohol and if so, how often and in what quantities]
- Drug Use: [Specify if the patient uses recreational drugs or has a history of drug use]
- Diet: [Provide information about the patient's dietary habits, including any special diets]
- Exercise: [Describe the patient's level of physical activity]

[Review of Systems]
- [List and briefly describe the patient's symptoms or concerns related to various body systems, including cardiovascular, respiratory, gastrointestinal, musculoskeletal, etc.]

[Social and Environmental History]
- [Include information about the patient's living situation, relationships, and any environmental factors that may be relevant to their health]

[Psychosocial History]
- [Note any significant mental health history or psychosocial stressors]

[Sexual History]
- [Include relevant sexual history information if applicable]

[Substance Use History]
- [Detail any history of alcohol or substance abuse, if applicable]

[Physical Examination Findings]
- [Summarize any relevant physical examination findings, including vital signs, general appearance, and specific organ system assessments]

[Assessment and Plan]
- [Provide a brief assessment of the patient's current medical condition and a plan for further evaluation and treatment]

[Provider's Name and Credentials]
- [Name of the healthcare provider]
- [Credentials, such as MD, DO, NP, PA]

[Date]
- [Date of the clinical history]

[Signature]
- [Signature of the healthcare provider]





https://www.odonto.unam.mx/es/formatos-clinicos

Ejemplo de formato para historia clínica
Aquí te mostramos un formato para historia clínica (básico) que te servirá para recoger datos más importantes de los pacientes y que ayudarán para analizar su recorrido médico. 

Ficha de Identificación.

Nombre: ____________________________

Apellidos: _____________________________

Registro núm. _______________________________________________________

Sexo__________   Edad_____________  Cuarto________  Sala_______

Ocupación / Profesión: 

________________________________________________________

Motivo de la consulta:

_________________________________________________

Antecedentes Personales Patológicos. (Debe decir los antecedentes de importancia clínica. Tratamiento que recibe para cada situación comórbida y su duración).

Cardiovasculares____Pulmonares____Digestivos______Diabetes___

Renales______Quirúrgicos_____Alérgicos_____Transfusiones_____

Medicamentos: ____________________________________________ 

Especifique: _________________________________________________________________

Antecedentes Personales No Patológicos (Indicar todo lo relacionado a tabaquismo, uso de alcohol, así como diferentes adicciones y su duración.  Antecedentes sexuales del paciente)

Alcohol: ________________________________________________

Tabaquismo: ____________________________________________

Drogas: ________________________________________________

Inmunizaciones: _________________________________________

Otros: __________________________________________________

Antecedentes Familiares:

Padre:   Vivo   Si____     No____

Enfermedades que padece: _______________________________________

________________________________________________________________

________________________________________________________________

Madre: Viva   Si____  No____

Enfermedades que padece: ________________________________________

________________________________________________________________

Hermanos: ¿Cuántos? ______   Vivos _____

Enfermedades que padecen: ______________________________________

________________________________________________________________

Otros: 

Antecedentes Gineco-obstétricos:

Menarquía _________  Ritmo ____________  F.U.M.______________

G____         P_____          A______        C_______     I.V.S.A ______________

Uso de Métodos Anticonceptivos: Si ______  No _______

¿Cuáles? ________________________________________

_________________________________________________

Enfermedad actual del paciente

_________________________________________________

Exploración física.

Signos Vitales. T.A._____ (brazo derecho) T.A. (brazo izquierdo)__________F.C._______

Frec. Resp.________Temp.______Peso_____Talla_____IMC______

Cabeza y Cuello __________________________________________

________________________________________________________

________________________________________________________

Tórax __________________________________________________

Abdomen

________________________________

Extremidades

_______________________________________

Neurológico y estado mental

____________________________________________________________

Laboratorio

Estudios de Imagen

Otros: 

Lista de Problemas. (Tratar de orientar el proceso diagnóstico en base a agrupar los síntomas que nuestro paciente presenta, tratando de encontrar una explicación en la mayor parte de los casos  por una sola entidad. Por ejemplo: Paciente el cual acude por hematemesis al interrogatorio nos comenta sobre datos de síndrome dispéptico, pérdida de peso, todo esto probablemente se pudiera englobar en un solo problema)

Activo / Inactivo

1.-______________________

2.-______________________

3.-______________________

4.-______________________

5.-______________________

6.-______________________

7.-______________________

La jerarquía de los problemas va de acuerdo a su importancia y al motivo de consulta, en relación a activos son los problemas que en este momento presenta el paciente, por el contrario, los problemas inactivos son aquellos que en términos generales solo son antecedentes o aquellos activos que ya se resolvieron.

Exámenes complementarios: __________________________________

Diagnóstico: _________________________________________________

____________________________________________________________ 

Plan Terapéutico: ________________________________________

Nombre, apellido y cédula del médico tratante: ________________________________________