Twelve Commandments for General Medicine Clinical Record: Some Suggestions that are Not in the Text books

The aim of this article is to describe the main features of the family physician approach in taking clinical record of the patient that is not always cited in textbooks, and it allows among other things to differentiate the general practice from the one of other medical specialists. The following concepts are shown: 1) the clinical history have to starting from the context, before facing the medical complaint; 2) the consultation must be prepared before the patient is admitted, memorizing his previous history, so that we can dedicate all our attention and be able to integrate his communication mentally in his previous clinical history; 3) it should always be annotated the clinical history “as if that case you were going to publish”, to achieve a complete, lively and rich story; 4) it may seem that only one person - the patient - enters the consultation, but it is only apparently: with him enters his family or companions and other relevant actors, and this always has important meanings; 5) the individual clinical history is always familiar, and should integrate the exploration of contextual and psycho-social data, and of genetic risk assessment, being a useful tool the genogram; 6) the clinical history must be “decentralized” (from the point of view of the other); 7) in the clinical record should be collected the health resources / strengths of the patient (non-specific positive health resources, support network that the patient has, individual characteristics of the personality, their disease and the situation of the environment) ; 8) biographical and psycho-social registry (concerns, illusions, projects, priorities, wishes, etc.), social data (poverty, social isolation), and Impact of disease in patient-family, labour, and relation-life (disease understanding, fears, hopes); 9) the “master-problems” or health problems that concentrate the greatest importance, power or significance should be recognized and noted; 10) doctor-patient-family relationship; 11) It must be remembered that the clinical history is constructed and reconstructed as a sculptor sculpts a sculpture (continued attention); and 12) should be annotated, at the end of the consultation, certain security elements, such as what will I do if the patient returns for the same problem?

Keywords: Family physician; Family practice; Family Medical History; Medical Record; Personal Health Records; History Taking, Medical.