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APPENDIX 4 CLINICAL HISTORY AND POSTMORTEM REPORT Date examined Owner/manager PIC Property address RFID/NLS number Animal type Enterprise type Origin CATTLE or MEAT or SHEEP MILK or IMPORTED or Animal

How to fill out clinical history and post-mortem

How to fill out clinical history and post-mortem?

1. Begin by gathering relevant information about the patient's medical history, including any previous illnesses, surgeries, allergies, and medications.
2. Document the patient's chief complaint or reason for seeking medical attention. Include details about the duration and severity of symptoms.
3. Take a comprehensive medical history by interviewing the patient or their family members. Record information about their lifestyle, habits, and any underlying conditions that may be relevant.
4. Record the patient's vital signs, such as blood pressure, heart rate, and temperature. These measurements provide crucial baseline information.
5. Complete a thorough physical examination, noting any abnormalities, findings, or symptoms. Document the location, nature, and severity of any observed or reported issues.
6. Carry out any necessary diagnostic tests, such as blood tests, imaging studies, or biopsies. Include the results of these tests in the clinical history.
7. Once all relevant information has been collected, organize it chronologically in the clinical records. Ensure that the entries are clear, concise, and specific.

Who needs clinical history and post-mortem?

1. Healthcare professionals: Clinical history is essential for healthcare providers as it provides relevant information about the patient's medical background, symptoms, and potential risk factors. It helps them make accurate diagnoses, develop appropriate treatment plans, and monitor the patient's progress.
2. Researchers and academics: Clinical history is valuable for research purposes, as it allows scientists to analyze patterns, identify potential risk factors, and gain insight into disease progression. It also provides a foundation for further studies and advancements in medical knowledge.
3. Insurance companies: Clinical history helps insurance companies evaluate an individual's medical background and determine their insurability, premiums, and coverage offerings. It allows them to assess the risk associated with insuring a particular individual.
4. Legal professionals: Clinical history may be required in legal proceedings, such as medical malpractice cases or disability claims. It serves as evidence to support or refute allegations, providing a comprehensive understanding of the patient's medical condition.

In summary, filling out clinical history and post-mortem involves collecting and documenting relevant medical information, while individuals such as healthcare professionals, researchers, insurance companies, and legal professionals benefit from having access to this information.

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What is clinical history and post-mortem?

Clinical history refers to the documented medical records and information about a patient's health and medical conditions. Post-mortem, also known as an autopsy, is a medical examination performed on a deceased person to determine the cause of death.

Who is required to file clinical history and post-mortem?

Medical professionals such as doctors, pathologists, and medical examiners are typically responsible for filing clinical history and performing post-mortem examinations.

How to fill out clinical history and post-mortem?

Clinical history is filled out by gathering a patient's medical records, test results, and information about their health conditions. Post-mortem is conducted by performing a systematic examination of the deceased person's body, including internal organs, tissues, and other relevant samples.

What is the purpose of clinical history and post-mortem?

The purpose of clinical history is to provide a comprehensive overview of a patient's medical background, which helps in diagnosis, treatment planning, and monitoring their health. Post-mortem serves to determine the cause of death, investigate any suspicious circumstances, or contribute to medical research and education.

What information must be reported on clinical history and post-mortem?

Clinical history should include details such as the patient's medical conditions, previous surgeries, medications, family history, and allergies. Post-mortem reports include findings related to the deceased person's body, such as organ abnormalities, injuries, toxicology results, and cause of death.