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Articles on Digital medical history
- Articles & guides
Validated risk scores in premedication: RCRI, Duke Activity Status Index, Apfel score
Several validated scores are used in premedication to estimate risks before a procedure: the Revised Cardiac Risk Index (RCRI) for cardiac complications, the Duke Activity Status Index (DASI) for functional capacity and the Apfel score for the risk of postoperative nausea and vomiting (PONV). What all three scores have in common is that their validity depends on the completeness of the underlying medical history data.
· 5 min read - Articles & guides
Why the medical history is the blind spot in digitalising the surgical process
In many hospitals, patient education and consent are already digital, but the medical history is still taken on paper. In the pre-anaesthesia clinic in particular, this leads to follow-up questions, media discontinuities and delays in the OR schedule; it also removes the basis for individualised patient education. An end-to-end pre-admission process therefore begins with a structured digital medical history at home, whose data flows on into the HIS and into patient education.
· 9 min read - Articles & guides
Why an electronic record alone is not enough: structured data instead of a collection of PDFs
ELGA in Austria and the ePA in Germany solve an important problem: findings, medication plans and physicians' letters are available to patients and treating providers in one place instead of disappearing on paper or in separate practice systems. However, this only solves the question of access – not the question of data quality, i.e. whether ELGA or the ePA contain structured data. If an electronic record essentially remains a collection of scanned or exported PDF documents, the actual work also remains unchanged: every physician has to search the document for the relevant information again. This is exactly where a structured digital medical history comes in.
· 8 min read - Articles & guides
Smart medical history: how it differs from a digital questionnaire
A digital questionnaire only changes the medium: instead of paper, patients fill in a form on a device. A smart medical history asks adaptive follow-up questions, checks the information for completeness and prepares it in structured form for the physician's assessment. Its added value only materialises when the data are reused in the workflow – for patient education, consent and the HIS. It is not a medical device and replaces neither the physician's judgement nor the discussion with the physician.
· 6 min read - Articles & guides
Checking drug allergies and cross-allergies in the digital medical history
“Penicillin allergy” is one of the most frequent entries in the preoperative medical history – and one of the least precise. Without more detailed information on the type of reaction, time course and organ system affected, it is impossible to judge whether an allergy is actually present or whether certain alternative drugs can be considered. A structured digital allergy history can ask specifically for exactly the information that makes a reliable classification possible in the first place.
· 5 min read - Articles & guides
Avoiding duplicate diagnostics through a structured medical history – the cost factor for hospitals and health insurers
Repeated X-rays, laboratory samples drawn twice, preliminary examinations performed a second time: in the preoperative process, duplicate diagnostics rarely arise because a repeat examination is medically necessary. They arise because existing medical history and findings are lost, incomplete or not available in time at the transition between practice, outpatient clinic and ward. For hospitals, this means double staff and equipment time; for health insurers, double billing for the same clinical question. A structured digital medical history closes exactly this information gap before it leads to unnecessary diagnostics.
· 9 min read - Articles & guides
Mallampati classification and digital medical history: why airway assessment stays in the hospital
The Mallampati classification is a visual examination of the oral cavity that a trained person performs directly on the seated patient — it cannot be collected via a digital questionnaire. medudoc therefore supports airway assessment where a smart digital medical history is strongest: in the structured recording of the patient's history and in early, individual patient education on anaesthetic techniques and alternatives. The physical airway examination itself — including the Mallampati classification — continues to be performed in person by the physician at admission.
· 9 min read - Articles & guides
Preoperative admission process: where physician time is lost — and how that is changing
In the preoperative admission process, physician time is lost at three points: before the appointment through incomplete medical history forms, in the consent discussion through standard content repeated every day, and afterwards through media discontinuities in consent and HIS handover. In a prospective study at University Hospital Würzburg, median physician discussion time before cholecystectomy fell by 81% with video-assisted patient education; understanding and satisfaction remained high. The greatest effect comes from a process planned digitally from end to end.
· 6 min read