Medical records List

The anamnesis is the gathering of subjective data concerning a patient, comprising family and personal, signs and symptoms that you experience in your condition , experiences and , in particular, memories, which are used to analyze their clinical history. It is a medical history that may provide relevant information to diagnose possible diseases

Field Description
Initial call classification Options:
  • Consultations
  • Urgency
  • Transference
Attention origin Options:
  • General illness
  • Occupational disease
  • Catastrophic event
  • Mistreatment
  • Work accident
  • Aggression injury
  • Sports injury
Chief complaint Is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medical encounter. The patient's initial comments to a health care professional that help form the differential diagnosis
History of the present illness Refers to a detailed interview triggered by the main complaint or the present symptom, Includes location, quality, severity, duration, timing, context, modify factors, associated signs and symptoms
External cause Options:
  • ---------
  • Work accident (Version 1)
  • Car accident (Version 1)
  • Rabies accident (Version 1)
  • Ofídico accident (Version 1)
  • Another type of accident (Version 1)
  • Catastrophic event (Version 1)
  • Injury aggression (Version 1)
  • Self-inflicted injury (Version 1)
  • Suspected physical abuse (Version 1)
  • Suspected sexual abuse (Version 1)
  • Suspicion of sexual violence (Version 1)
  • Suspicion of emotional abuse (Version 1)
  • General disease (Version 1)
  • Professional illness (Version 1)
  • Other (Version 1)
  • Work accident
  • Accident at home
  • Traffic accident of common origin
  • Work-related traffic accident
  • Accident in the educational environment
  • Other type of accident
  • Catastrophic event of natural origin
  • Assault injury
  • self-inflicted injury
  • Suspected physical violence
  • Suspicion of psychological violence
  • Suspected sexual violence
  • Suspicion of negligence and abandonment
  • IVE related to danger to the health or life of the woman
  • IVE due to congenital malformation incompatible with life
  • IVE for sexual violence, incest or non-consensual artificial insemination or transfer of a fertilized egg
  • Adverse health event
  • General illness
  • Occupational illness
  • Health promotion and maintenance – individual interventions
  • Collective intervention
  • Perinatal maternal population care
  • Environmental risk
  • Other Catastrophic Events
  • Antipersonnel mine accident – MAP
  • Improvised Explosive Device Accident – AEI
  • Unexploded Ordnance Accident - UXO
  • Another victim of the Colombian armed conflict
Identifier of the cause that originates the health service. Report according to the table RIPSCausaExternaVersion2 in web.sispro.gov.co
Alert This alert will appear as an eye-catching message each time this patient is searched. It is not shown in the medical record impression. It is useful to leave messages that can not be ignored

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