Medical findings
When finding medically relevant, physical or psychological symptoms, conditions, changes and conditions of a patient be referred to by appropriately trained personnel (doctors, naturopaths, etc. ) is collected as a result of examination by means of different inspections, methods and tools and documented in various ways ( text, graphics, images, sound, etc.).
Report of findings, documentation and patient records
The diagnosis usually follows a systematic investigation carried out. A summary of all individual results can be found in an inspection report, with the results always refer to the time of investigation. The present status denotes the current state of the patient. If a particular examination shows no pathological findings, but normal findings, usually a documentary by the abbreviation "or B. "(without finding).
An overall findings thus represents the sum of all collected individual findings and is usually part of a Epicrisis. Since a finding relates to identified, inter- subjective phenomena, it is distinguished from the medical history, subjective complaints of the patient.
The preparation and documentation of a finding is one of the essential duties of the medical profession, especially in view of the evidence of achievement for billing questions, and in the case of legal disputes. The diagnosis can be stated in appropriate documentation forms. Chief complaint and associated complaints lead to tentative diagnoses, this in turn for the targeted clinical results and finally to working diagnosis and therapy. In addition, findings are structured documentation of communication and cooperation between all parties involved physicians, hospitals and institutions, which is increasingly supported by the development of telemedicine. Be documented more structured and standardized results, the better they are to be compared and to assess disease progression. This is especially evident in specialist areas where often numerical results are collected, such as in ophthalmology ( visual acuity, intraocular pressure, refraction and spectacles values , stereopsis, strabismus, etc.).
The Patients' Rights Act, the physician or dentist was amended by § 630fVorlage: § / Maintenance / buzer BGB obliged - as previously already regulated in the professional codes and federal sheath contracts - to keep patient records and all relevant facts, including the findings include, in detail to document. Subsequent changes in both the run on paper, as well as in the electronic medical record must indicate the specific content and the exact time of the change.
Demarcation
From the medical history (anamnesis ) and a constellation of findings gained a doctor can derive a diagnosis, which he attributes to the patient a disease entity. Findings that can not be explained by a diagnosed disease are referred to as secondary findings, which in turn may represent symptoms of other diseases that require further diagnostic evaluation.
Collected test results, according to which it is explicitly sought, called incidental findings.
Although this is often not clearly distinguished in everyday language, findings and symptom are distinguishable from each other. While the term finding the empirical character highlights ( the collection of information ) of detected features, emphasizes the appearance of a characteristic symptom itself, as an indication of disease.
Swell
- Jürgen Dahmer: History and signs. Thieme Verlag, 2006. ISBN 3-13-455810-6