Why Patient Records Should Have Honest Contents

Why Patient Records Should Have Honest Contents

ENT clinics are the first point of entry for any person experiencing ears, nose and throat conditions, disease and discomfort. Because ENT has the most common ones in any expertise, surely once a year even you would visit in one. When visiting an ENT clinic and any other clinic, in general, you can expect that there will be history taking, initial assessment, tests, prescriptions, management and a follow-up checkup.

In those days where the doctor is trying to know what makes you ill, it’s important that you will be honest with what you feel and your history since health care providers will assume that what you’re saying on paper is the truth and will be the basis for treatment. If you’re wondering what those are, you can find them below.

History taking should be taken seriously: There are people that don’t take history taking seriously and either they are lying or they just don’t care and wants to piss the healthcare provider off. But you should know that history taking is for you and it’s drastically used in order to give you a very specific plan of care and treatment. In the end, it’s not going to be the healthcare provider that’s going to suffer but the customer since they are getting not the ideal or a specific plan of care or treatment for them. While history takings are lengthy, its necessary.

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Don’t lie about what you’re feeling: Most people think that when it comes to the details of their condition or disease that its okay to  lie about it. You should know that this is also as serious as not giving out complete history about you. It can lead to false diagnosis, a wrong drug to even the wrong treatment. Surely you’ve seen a lot of people in tv series and movies lying about what they are feeling and they got it pretty bad. The fact is, patient records are confidential and no one but the health care team that handled your case and a few big people that handle the area where you belong will have access to it. So if you’re afraid that some people will know what your diagnosis is, they won’t.

Follow application or dosage instructions: If the doctor told you that antibiotics should be taken with this dosage and this timeline and for these days, you should follow it and so does with any other drugs. This is because its what it was intended for. Say the doctor told you that you are to take 500mg of antibiotic three times a day for 7 days. The reason you were given that dose and timeline is because that is what it takes for you to be fully healed. Taking less dosage or stopping before the designated timeline can possibly just make the bacteria more potent and you will require more antibiotic treatment with a stronger antibiotic.

You have to understand that giving treatment is a systemic approach and sometimes collaborative. The basis for the treatment and care are the things that come out of your mouth like history taking and the things that you feel. So if you don’t want them to be wrong, then tell the truth because if they do get it wrong its all you that will suffer and besides, your records are confidential. But of course, this starts with a good clinic that has a well known good practice like Dr Zacharia Sydney clinic.