Patient documentation & medical history – digital practice management

Personal contact – The medical history interview

The word ‘anamnesis’ comes from Greek and means ‘memory’. It refers to the history of an illness, including previous conditions and cases of illness in the family. The nature, onset and progression of current health problems are discussed during the consultation and form the basis for treatment. The aim of the anamnesis is to gather information in order to proceed with effective treatment and to discover the limits of one’s own scope of practice.

It is important to take experience, build trust and communicate on an equal footing to ensure that explanations are understood.

Ask yourself the following questions:

What personal qualities do I have?
How do I respond to my patients?
Am I behaving tactfully?
Am I giving my patients adequate attention?
Do I discover that I am genuinely willing to help?

What should I document?

Comprehensive documentation enables you to write therapy reports, which can be used, for example, to communicate with doctors. When documenting accurately, the following three questions are fundamental:

What findings were recorded?
What diagnoses were given?
What treatment was performed?

Information on patients’ symptoms and problems should be structured in such a way that the importance of each point is clear. In addition, details should be given regarding any operations, fractures and habits relating to sport, work and general stress in everyday life. Furthermore, regularly taken medication should be documented. Also important are readings for pulse, monofilament, tuning fork and temperature – and, of course, the results of visual and palpation findings.

The aim of thorough documentation is to clarify the course of healing and treatment, to review your own approach and to prepare suitable advice for patients. You can provide a clear rationale for your courses of action based on your documented data. Do not forget to date everything accurately.

Practice management software: Retain important data centrally and clearly

Patient data is key to your work, ranging from addresses and therapy reports to treatment records. Practice management software helps you to retain this data in a clear and organised manner and manage it centrally.
pododesk is our practice management software, designed specifically to meet the unique requirements of podiatry and foot health. In pododesk, you can create fully complete patient records, including name, address, health insurance details and contact information, along with a photo. Important documents and files can be stored centrally.

In pododesk, you can retain and manage your fully complete patient records. From name and address to health insurance details and contact information, including a photo, you can quickly and easily find all the patient’s personal details within the patient record. You can also retain important documents and files centrally here.

The patient records feature in pododesk enables the management of prescriptions, appointments, medical histories, test results and treatment records. This facilitates teamwork and eliminates the need for paper records.

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Medical history and findings

As a key component of your medical treatment, it is important to understand and document the medical history and current condition of the feet being treated. pododesk includes a professionally designed template for both and guides you through the data entry process thanks to nine simple steps. In practical terms, this means that after answering a few specific questions, you will have a structured overview of your patients. You can, of course, also record any individual comments or observations . Changes that occur during the course of treatment are also widely documented. This means that, if necessary, you can access the historical data at any time.

Treatment records, including photographs

Of course, for legal reasons, meticulous documentation of your treatments is also part of your duties. pododesk makes this process easier for you. pododesk automatically links your entries to the appointment and, where applicable, to the corresponding prescription for medical products. All you need to do is describe the treatment you have carried out and specify the batch number for the sterilisation of all instruments. pododesk also ensures the ‘immutability’ of the entries in accordance with legal requirements. You can, of course, still give comments and additional details; these will be widely documented. Along with written documentation, you can upload one or more photos along with documents.

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Treatment reports

As part of your work, you will occasionally need to write a treatment report for the attending doctor . In some cases, the Medicines Regulation even requires you to produce a therapy report. You can simply upload your report, prepared as usual, to pododesk and assign it to the relevant patient or prescription . Then the details are accessible at any time, and pododesk knows that you have met your obligation under the Medicines Regulation.