sairaushistoria

Sairaushistoria, or medical history, is the record of a person’s health-related information used by clinicians to guide care. In Finnish contexts the term is often written as sairaushistoria. It typically includes past illnesses and surgeries, hospitalizations, current and recent medications, allergies, immunization status, and family health history, as well as social and lifestyle factors that influence health.

Core elements commonly found in a medical history include historical and current diagnoses, chronic conditions, obstetric history where relevant, medications (prescribed and over-the-counter), allergies and adverse drug reactions, immunizations, prior procedures, and family history of genetic conditions. Social history may cover tobacco, alcohol or drug use, occupation, living conditions, travel, and exposure risks. Documented information may originate from patient interviews, intake forms, and existing records, and is updated over time.

Collection and use: Information is gathered by clinicians during intake and through subsequent visits, and is often stored in electronic health records for access by authorized personnel. The medical history informs differential diagnoses, risk assessment, preventive strategies, treatment planning, and coordination of care across providers. It also helps identify potential drug interactions and contraindications.

Privacy and accuracy: Medical histories are confidential and protected by privacy laws. Patients typically have rights to access and correct their records, and clinicians should verify information with the patient and obtain consent for sharing when required. The accuracy and completeness of the history are essential for safe and effective care.

Challenges: Recall bias, language barriers, and fragmented or incomplete records can hinder completeness. Ongoing communication and clear questioning help mitigate these issues.