<P> The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files . The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research . </P> <P> Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records . </P> <P> The medical history is a longitudinal record of what has happened to the patient since birth . It chronicles diseases, major and minor illnesses, as well as growth landmarks . It gives the clinician a feel for what has happened before to the patient . As a result, it may often give clues to current disease state . It includes several subsets detailed below . </P> <Dl> <Dt> Surgical history </Dt> <Dd> The surgical history is a chronicle of surgery performed for the patient . It may have dates of operations, operative reports, and / or the detailed narrative of what the surgeon did . </Dd> <Dt> Obstetric history </Dt> <Dd> The obstetric history lists prior pregnancies and their outcomes . It also includes any complications of these pregnancies . </Dd> <Dt> Medications and medical allergies </Dt> <Dd> The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies . </Dd> <Dt> Family history </Dt> <Dd> The family history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other . It may also include a pedigree chart . It is a valuable asset in predicting some outcomes for the patient . </Dd> <Dt> Social history </Dt> <Dd> The social history is a chronicle of human interactions . It tells of the relationships of the patient, his / her careers and trainings, and religious training . It is helpful for the physician to know what sorts of community support the patient might expect during a major illness . It may explain the behavior of the patient in relation to illness or loss . It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos). </Dd> <Dt> Habits </Dt> <Dd> Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history . This section may also include more intimate details such as sexual habits and sexual orientation . </Dd> <Dt> Immunization history </Dt> <Dd> The history of vaccination is included . Any blood tests proving immunity will also be included in this section . </Dd> <Dt> Growth chart and developmental history </Dt> <Dd> For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health - care providers can follow the child's growth over time . Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness . Additionally, a child's behavior (such as timing of talking, walking, etc .) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth . </Dd> </Dl>

Describe the purpose of the various formats that exist for documenting care