El razonamiento clínico llevado a la historia clínica. Un punto de vista diferente

MEDISUR

Edwis Pérez Pintado¹  Yagén María Pomares Pérez¹  Ariel Efrén Uriarte Méndez¹ 

[1] Hospital Pediátrico Provincial Paquito González Cueto

关键词: registros médicos;    competencia clínica;    calidad de la atención de salud;   

DOI  :  

学科分类：医学（综合）

来源: Centro Provincial de Informacion de Ciencias Medicas de Cinfuegos

【 摘 要 】

There have been serious deficiencies in the completion of medical records over the years, being the diagnostic discussion the section with more difficulties. This paper analyses such deficiencies, responsible for the lack of the most basic features and functions of medical records. It tries to get to the source of the poor quality of diagnostic discussions, while proposing a different approach that could solve the problem. We conclude that the problem is related to the unconditional requirement of a rigid structure, not applicable to all situations, which causes the adherence to this structure to affect the logical clinical reasoning.

【 授权许可】

CC BY