How Electronic Medical Records Work: The Structure and Clinical Role of “Medical History and Documentation”
The Medical History and Documentation section is one of the most critical components of an Electronic Medical Record (EMR). It serves as the foundation for clinical decision-making, treatment planning, and patient safety — especially in preventive and rehabilitative healthcare settings such as sanatoriums and resort treatment centers.
In this article, we explore the structure, content, and clinical significance of the medical history section in EMRs, with a focus on best practices for data collection, integration, and compliance in the context of resort medicine.
What Is a Medical History in an Electronic Medical Record?
The medical history (or anamnesis) is a comprehensive, structured record of a patient’s health background. Unlike traditional paper-based charts, where information was often handwritten and disorganized, the digital medical history in an EMR is standardized, searchable, and integrated with other clinical modules.
It enables healthcare providers to:
- Quickly assess a patient’s overall health status;
- Identify contraindications and risk factors;
- Personalize treatment plans;
- Ensure continuity of care across different medical institutions.
In sanatoriums, where the focus is on rehabilitation, prevention, and long-term wellness, a well-documented medical history is essential for safe and effective resort therapy.
Key Components of the Medical History Section in EMR
1. Patient Demographics
- Full name, date of birth, gender;
- Contact details (phone, email);
- Residential and legal address;
- Insurance information (OMS/DMS).
This data is typically auto-populated from the Unified State Health Information System (EGISZ) or entered during patient registration.
2. Chief Complaints
- Primary symptoms at the time of admission (e.g., back pain, insomnia, fatigue);
- Duration, intensity, and triggers;
- Use of standardized pain scales (e.g., VAS, NRS).
In EMR systems, these complaints are often linked to diagnostic codes (ICD-10) for better tracking and analysis.
3. History of Present Illness
- Onset, progression, and severity of the current condition;
- Previous treatments and hospitalizations;
- Response to therapy.
For sanatoriums, it’s important to document how the patient tolerates changes in climate, routine, and physical activity — all of which can influence chronic conditions.
4. Chronic Conditions
- List of diagnosed diseases with dates of onset and progression;
- Frequency of exacerbations;
- Medications in use.
Example:
Ischemic heart disease, stable angina (FC II), post-MI (2020). On beta-blockers and statins.
This information helps determine eligibility for specific resort treatments.
5. Surgical and Trauma History
- Dates and types of surgeries (e.g., hip arthroplasty, appendectomy);
- Postoperative complications;
- History of fractures or injuries.
This is crucial in sanatoriums when planning physical therapy (LFK), hydrotherapy, or massage, where certain procedures may be contraindicated.
6. Allergies and Adverse Reactions
- Drug allergies (e.g., penicillin, NSAIDs);
- Food, seasonal, or environmental allergies;
- Severity of reactions (rash, anaphylaxis, etc.).
In EMR systems, allergy alerts are often highlighted with icons or color codes to prevent medication errors.
7. Family (Genetic) History
- Chronic or hereditary conditions in close relatives:
- Cardiovascular diseases;
- Cancer;
- Diabetes;
- Mental health disorders.
While not always directly actionable, this data supports risk assessment and preventive strategies.
8. Epidemiological and Vaccination History
- History of infectious diseases (TB, hepatitis, HIV, COVID-19);
- Vaccination records (flu, pneumococcal, COVID-19).
In a group setting like a sanatorium, this information is vital for infection control and outbreak prevention.
9. Lifestyle and Social History
- Smoking (pack-years);
- Alcohol consumption;
- Physical activity level;
- Diet and sleep patterns;
- Occupation and working conditions.
This section is especially valuable in preventive and wellness programs, where lifestyle modification is a key goal.
Special Considerations in Sanatorium Settings
In sanatoriums, the medical history is not just a diagnostic tool — it’s the basis for individualized rehabilitation planning. Key features include:
Focus on Contraindications
Many spa procedures — such as mud therapy, radon baths, or halotherapy — have strict contraindications. A properly filled EMR can automatically flag risks based on patient history.
Example:
History of malignancy → system blocks mud therapy and alerts the physician.
Dynamic Updates
The medical history is not static. During a patient’s stay, new symptoms or test results may emerge. Modern EMRs allow real-time updates with audit trails showing who made changes and when.
Integration with Referral and Discharge Documents
Upon admission, patients provide:
- Hospital discharge summaries;
- Referral for spa treatment (SCL);
- Recent lab and imaging results.
These documents are attached to the medical history section in digital form, ensuring legal compliance and clinical completeness.
Automated Clinical Summaries
Advanced EMR systems like SandSoft Sanatorium can generate physician conclusions automatically based on entered data, reducing documentation time and minimizing omissions.
Regulatory Requirements for Medical History in EMR
According to Russian healthcare regulations (Ministry of Health orders, SanPiN 2.5.3658-20, Federal Law No. 323-FZ), the digital medical history must meet the following standards:
- Accuracy — all data must be verified and documented;
- Completeness — no missing mandatory fields;
- Access control — only authorized personnel may view or edit;
- Audit trail — every change is logged with timestamp and user ID;
- Retention period — at least 25 years.
Advantages of Digital Medical History vs. Paper-Based Records
| Feature | Paper-Based Record | Electronic Medical Record |
|---|---|---|
| Data Search | Manual, time-consuming | Instant, keyword-based |
| Legibility | Depends on handwriting | Always clear and standardized |
| Accessibility | Limited to physical location | Remote access (with consent) |
| Integration | None | Linked to EGISZ, MIS, telemedicine |
| Security | Risk of loss or tampering | Encrypted, role-based access |
Best Practices for Managing Medical History in EMR
- Conduct a thorough intake interview upon admission — ideally with a resort physician present.
- Use standardized templates to ensure consistency and completeness.
- Update the record regularly — especially if the patient’s condition changes.
- Train medical staff — nurses and administrators should understand the importance of each data field.
- Choose specialized software — such as SandSoft Sanatorium, designed specifically for the workflows of resort medicine, with built-in compliance, automation, and safety alerts.
Conclusion
The “Medical History and Documentation” section in an Electronic Medical Record is far more than a digital form — it is the clinical cornerstone of personalized, safe, and effective patient care. In sanatoriums, where treatment is preventive and long-term, this section plays an even greater role in shaping therapy plans and minimizing risks.
Digital transformation allows healthcare providers to turn medical history from a bureaucratic task into a powerful clinical tool. When implemented correctly — with structured data entry, real-time updates, and integration with treatment systems — EMR significantly improves patient outcomes.
Solutions like SandSoft Sanatorium offer a tailored, compliant, and user-friendly approach to managing medical histories in resort settings, making digital documentation not a burden, but a strategic advantage.