One medical history for the whole procedure
The digital medical history from medudoc captures health data in structured form instead of on paper. Surgery and anaesthesia ask their questions in one shared questionnaire – each item is collected only once, step by step in the browser.
Structured data
Only structure makes information usable
A paper questionnaire collects free text – often illegible, incomplete and impossible to evaluate. Before your team can work with it, someone has to follow up and type it in. The digital medical history captures every item as a structured value.
- Allergies: penicilin? (as a child)unclear
- Medication: blood pressure pill, sugar tabl.product missing
- Previous surgery: knee, 2015 or 2016imprecise
- Weight:missing
- Penicillin · skin rash · childhood
- SNOMED CT
- Ramipril 5 mg · 1-0-0
- PZN
- Metformin 1000 mg · 1-0-1
- PZN
- Arthroscopy left knee · 2016
- SNOMED CT
- 178 cm · 82 kg · BMI 25.9
Complete
The medical history checks the information for completeness before the case reaches your team.
Consistent
Information is normalised to SNOMED CT – the same facts, the same codes.
Reusable
The same data supports risk assessment, personalised patient education and the handover to your systems.
The same questions. Twice. On paper.
Before many procedures, patients first fill in a surgical questionnaire and then an anaesthesia questionnaire. They answer questions on pre-existing conditions, medication and allergies twice – and then someone types up both.
One questionnaire instead of two
Every item collected only once
medudoc combines surgical and anaesthesia questions in one combined questionnaire per procedure. Shared topics are captured once and supplemented by specialty-specific questions. Both specialties work with the same data.
Surgical questionnaire
- Pre-existing conditions
- Medication
- Allergies
- Previous surgery
- Symptoms and history
Anaesthesia questionnaire
- Pre-existing conditions
- Medication
- Allergies
- Previous surgery
- Previous anaesthesia, airway
Combined questionnaire
- Pre-existing conditionsShared
- MedicationShared
- AllergiesShared
- Previous surgeryShared
- Symptoms and historySurgery
- Previous anaesthesia, airwayAnaesthesia
- Less effort and frustration for patients
- No contradictory duplicate entries
- One data set for surgery and anaesthesia
Questions with a system
Matched to the procedure, specific to every answer
The digital medical history does not ask everyone every question. It asks what is relevant for this procedure and this person – and goes into depth where an answer calls for it.
One questionnaire per procedure
Every procedure has its own questionnaire. It is based on established standards and is created and maintained by medudoc itself.
Adaptive follow-up questions
Anyone who reports an allergy is asked about the trigger, reaction and timing. Anyone without one skips the section. The result is a precise medical history without unnecessary questions.
In the patient's language
The medical history is multilingual. Patients choose their language at the start and answer as precisely as they can in their own language.
Input forms for medical staff
If medical staff capture the medical history themselves, for example in an emergency, dedicated input forms are available for quick entry. The case is the same afterwards.
Other forms from your hospital
Patients fill in the hospital's own forms and consents in the same session. Whatever can be captured or signed digitally is included.
Do you have any allergies?
If "No": continue with medication
- Follow-up question
What are you allergic to?
- Follow-up question
How did the reaction show itself?
- Follow-up question
When did it last occur?
Medication and findings
Take a photo instead of typing
Copying medication names and lab values by hand is tedious and error-prone. That is why patients capture them with the camera and by upload.
Medication by photo
Patients take a photo of the package or their medication plan, in Germany for example the nationwide standard medication plan. medudoc recognises the products via an integrated drug database.
- Photograph the package or medication plan
- Matching against the drug database
- Add dosage schedule and reason directly
Upload findings, transfer values
Patients simply upload previous findings. medudoc reads out relevant information, stores it in structured form and suggests matching answers in the medical history.
- Relevant values read out automatically
- Suggested answers that patients confirm
- Source reference for the physician's review
Handover
Stored in structured form, ready for your systems
medudoc stores all information in structured form, normalised to SNOMED CT. Downstream systems receive it via the Platform API or as an HL7 FHIR QuestionnaireResponse – no retyping and no media breaks.
- Handover to HIS, PDMS and archive system
- HL7 FHIR QuestionnaireResponse or Platform API
- The same data supports risk assessment, patient education and consent
- QuestionnaireResponse
- status: completed
- questionnaire: Combined questionnaire [procedure]
- item: Allergies
- Penicillin · SNOMED CT
- Reaction: skin rash · childhood
- item: Medication
- Ramipril 5 mg · 1-0-0
- Metformin 1000 mg · 1-0-1
- # to HIS, PDMS and archive system
The workflow around the medical history
- Patient intakeAccess via QR code, website link or appointment confirmation – no app, no new password.Learn more
- Validation & risk assessmentRisk factors and key figures for each case, prepared for medical assessment.Learn more
- Patient education videoPersonalised patient education videos for each procedure, with subtitles and a reading version.Learn more
- Digital consent sheetPatient-specific consent sheet with electronic signature.Learn more
See the combined questionnaire for your procedures
In a demo, we show you the digital medical history from your patients' perspective and the structured data from your team's perspective.