ABSTRACT
RESUMO Objetivo identificar, coletar e analisar, na literatura científica, evidências da existência de protocolos fonoaudiológicos de levantamento da história clínica, conforme classificação de risco, especialmente para distúrbios oromiofuncionais, em lactentes e pré-escolares. Estratégia de pesquisa foram selecionados estudos publicados, sem delimitação temporal, nas bases de dados eletrônicas LILACS, SciELO e PubMed e na literatura cinza (Google Acadêmico). Critérios de seleção estudos disponíveis na íntegra nas línguas portuguesa e inglesa, que identificassem protocolos fonoaudiológicos de história clínica aplicáveis a lactentes (6 a 23 meses de vida) e pré-escolares (24 a 71 meses de vida). Foram excluídas as revisões narrativas e de literatura (integrativa, sistêmica e escopo). Resultados foram encontradas 1371 publicações brasileiras no período de 1980 a 2022. Destas, foram identificadas apenas cinco que tratavam de protocolos fonoaudiológicos para levantamento de dados pregressos a partir da história clínica da faixa etária de 6 a 71 meses. Apenas um desses protocolos possuía classificação de risco para distúrbios fonoaudiológicos, distribuídos na área de linguagem e fluência. Os outros três eram da área de motricidade orofacial (MO) e não continham classificação de risco para distúrbio miofuncional orofacial. Conclusão existem poucos protocolos fonoaudiológicos para levantamento da história clínica de lactentes e pré-escolares que contenham, ou não, classificação de risco, publicados em revistas de acesso aberto e que passaram por processos completos de validação, sendo necessário ampliar estudos e publicações desses instrumentos, inclusive na área de MO.
ABSTRACT Purpose to identify, collect and analyze in the scientific literature evidence of the existence of speech therapy protocols for collecting clinical history, according to risk classification, especially for oromyofunctional disorders, in infants and preschoolers. Research Strategy We selected published studies, without temporal delimitation, in the electronic databases LILACS, SciELO and PUBMED; and in the gray literature (Google Academic). Selection criteria available in full in Portuguese and English, which identify speech-language pathology protocols of clinical history applicable to infants (6 to 23 months of age) and preschoolers (24 to 71 months of age). Narrative and literature reviews (integrative, systemic, and scope) were excluded. Results 1371 Brazilian publications were found in the period from 1980 to 2022. Of these, only five publications on speech therapy protocols were identified for collecting previous data from the clinical history of the age group between 6 and 71 months. Only two of these protocols have a risk classification for speech-language disorders, distributed in the areas of language and fluency. The other three are from the Orofacial Motricity (OM) area and do not carry a risk classification for orofacial myofunctional disorder. Conclusion There are few speech therapy protocols for surveying the clinical history of infants and preschoolers, whether or not they contain risk classification, published in open access journals that have a complete validation process.Therefore there is a need for more research and publication of these instruments, including in the area of OM.
Subject(s)
Humans , Infant , Child, Preschool , Stomatognathic System/physiopathology , Risk Factors , Stomatognathic System Abnormalities , Speech, Language and Hearing Sciences , Medical History Taking/methodsABSTRACT
El dolor abdominal es una causa frecuente de consulta ambulatoria, sus causas son múltiples e incluyen patologías de riesgo vital u otras de bajo riesgo que requieren principalmente tratamiento y no requieren mayores estudios. La historia clínica y el examen físico son las herramientas principales para poder sospechar la etiología de la enfermedad que está causando el dolor abdominal. Es por esto que realizar una historia completa, haciendo preguntas dirigidas a confirmar o descartar sospechas diagnósticas, asociado a un examen físico completo y sistemático, es la principal forma de orientar el diagnóstico y estudio posterior del paciente. Conocer el cuadro clínico de las enfermedades que dentro de sus síntomas pueden presentar dolor abdominal, especialmente aquellas que son de riesgo vital permite poder diagnosticarlas con la rapidez que se requiere. Así mismo, es necesario reconocer aquellas enfermedades que son más frecuentes y que no requieren mayores estudios sino tratamiento básico, habitualmente ambulatorio. Existen personas que, por sus condiciones de salud o edad, pueden tener presentaciones atípicas de cuadros habituales o mayores riesgos de tener enfermedades infrecuentes o de mayor riesgo vital, que es importante reconocer al momento de la evaluación.
Abdominal pain is a common complaint in ambulatory medicine. It has multiples causes,including lifethreatening pathologies and other benign in which the need in treatment and no other tests. The clinical history and physical examination are the key to suspect the etiology of the underlying disease. A complete history includes make direct questions to confirm or discard the diagnostic suspects and with a complete and systematic physical examination are the main way to get the diagnosis and treatment of the patient. The clinician must know the syndromes which includes abdominal pain, especially those life-threatening which requires urgent treatment or surgery. Also needs to know the frequent benign syndromes that can be safely treated symptomatically with no further investigation. Older adults or patients with comorbidities may present with unusual causes of abdominal pain or may have an atypical presentation of common disorders. Also, may present more frequent serious etiologies that may require urgent interventions.
Subject(s)
Humans , Abdominal Pain/diagnosis , Abdominal Pain/etiology , Physical ExaminationABSTRACT
RESUMEN La historia clínica es un documento oficial que exige una redacción rigurosa, pues en ella quedan plasmados datos esenciales del paciente y su padecimiento; así como el tratamiento y las evidencias de su evolución. Debido a lo anterior, es necesario un programa que organice las etapas por las que transita el estudiante para aprender a escribirla. Por ello, el objetivo del presente texto es exponer elementos de un programa que contribuye al desarrollo de habilidades para la redacción de la historia clínica en los estudiantes del tercer año de la carrera Estomatología. Se revisó la literatura científica especializada de cubanos y extranjerosreferida a la temática. Se estudiaron documentos oficiales para conocer los objetivos del modelo del profesional de la carrera Estomatología, así como el programa de la asignatura Propedéutica Clínica y Semiología Estomatológica. Se constataron dificultades en los estudiantes para redactar las historias clínicas y que no existe, al menos en la literatura consultada, un programa que organice las etapas para concretar este proceso. Se propone un programa que brinda orientaciones metodológicas encaminadas a este propósito. El programa permite que los estudiantes sean protagonistas de su proceso de aprendizaje de la redacción de las HC y de su autoevaluación. La investigación constituye una experiencia didáctica puesta en práctica durante el año 2019.
ABSTRACT The clinical history is an official document that requires rigorous drafting, since it contains essential data about the patient and his condition; as well as thetreatment and evidence of his evolution. Due to the above, a program is necessary that organizes the stages the student goes through to learn to write it. Therefore, the objective of this text is to present elements of a program that contributes to the development of skills for the writing of clinical history in students of the third year of the Dentistry career. The specialized scientific literature of Cubans and foreigners on the subject was reviewed. Official documents were studied to know the objectives of the professional model of the Dentistry career, as well as the program of the Clinical Propedeutics and Dentistry Semiology subject. Difficulties were found in the students to write medical records and that there is not, at least in the literature consulted, a program that organizes the stages to specify this process. A program is proposed that provides methodological guidelines for this purpose. The program allows students to be protagonists of their learning process of writing the HC and of theirself-evaluation. There search constitutes a didactic experience put in to practice during the year 2019.
ABSTRACT
Background: Neonatal hyperbilirubinemia is defined as serum bilirubin levels >7 mg/dl around 85% of all term newborns and most of the premature babies develop clinical jaundice and various associated risk factors are involved in NNH and treatment for this condition depends on gestational age, serum bilirubin levels at different time interval during early life of these newborns and treating them with phototherapy or exchange transfusion. Objective of the study was to establish the relation with the NNH and risk factors among newborns and treatment with the phototherapy if required.Methods: The present prospective study was conducted at Karuna Medical College, Chittur Palakkad from January 2019 to December 2019. A total of 40 samples which are born during the study period were included in the study. All types of gestations (preterm, full term, post term), both genders (male and female), new-borns with risk factors, serum bilirubin (TSB) >7 mg/dl at 48 hrs of life were included in the studyResults: In our study, female samples consists of 55% and male samples were 45% during the study period minimum gestational age was 35 weeks and maximum was 40 weeks. 5% sample with a serum bilirubin level of 9 mg/dl,' with risk factor as a Rh(-ve) incompatibility was treated with phototherapy up to 96 hrs of life.Conclusions: Study conveys various risk factors responsible for NNH and treatment with phototherapy given to the affected new-borns. With good clinical history, risk factors involved in new-borns, antenatal counseling is needed to all pregnant women's it is necessary to check the serum bilirubin levels and treated with phototherapy to avoid further NNH related complications in the new-borns.
ABSTRACT
El síndrome de Guillain-Barré constituye una entidad de etiología diversa, que se caracteriza por debilidad muscular aguda, simétrica, ascendente y progresiva, y es una de las polineuropatías adquiridas más frecuentes en la infancia. Entre los diagnósticos diferenciales, deben considerarse las neuropatías producidas por metales pesados, mercurio y plomo, y metaloides, como el arsénico, plaguicidas organofosforados y el tetracloruro de carbono.Se presenta a un paciente de 14 años con diagnóstico de síndrome de Guillain-Barré sin respuesta al tratamiento convencional con gammaglobulina. Considerando otras etiologías, se sospechó neuropatía producida por metales pesados, y se confirmó intoxicación por mercurio.El objetivo de esta presentación es concientizar a los pediatras acerca del impacto de los tóxicos ambientales en la salud infantil para realizar un diagnóstico precoz pesquisando datos clave a través de la historia clínica ambiental
Guillain-Barré syndrome is an entity of diverse etiology, characterized by acute, symmetric, ascending and progressive muscle weakness, being one of the most frequent acquired polyneuropathies in childhood. Neuropathies produced by heavy metals, mercury and lead, and metalloids, such as arsenic, organophosphorus pesticides and carbon tetrachloride, should be considered among the differential diagnoses.We present a 14-year-old patient with a presumptive diagnosis of Guillain-Barré syndrome without response to conventional treatment with gamma globulin. Considering other etiologies, heavy metal neuropathy was suspected, and mercury poisoning was confirmed.The aim of this presentation is to make pediatricians aware about the impact of environmental toxic agents on children's health in order to make an early diagnosis by researching key data through the environmental clinical history.
Subject(s)
Humans , Male , Adolescent , Mercury Poisoning, Nervous System/diagnosis , Polyneuropathies , Heavy Metal Poisoning, Nervous System/drug therapy , Environmental Exposure/adverse effectsABSTRACT
@#The health of the skeletal system is a vital issue in elderlies, hence, screening studies that investigate elders’ bone health and identify associated factors affecting bone density are of prime importance. This study purposed to evaluate bone mineral density levels and examine its relationship with socio-demographic and clinical data, and body measurements among Jordanian elderlies aged 60 years and over. Methods: A cross-sectional, descriptive correlational study was used using a systematic random sampling technique to recruit 155 participants in Amman governorate. A questionnaire consists of socio-demographic and clinical data, and a form measures bone mineral density and body mass index were used. Bone mineral density was measured using a CM200 light device, where the T-score used to assess the bone mineral density. The T -scores equal -1 < -2.5 indicate osteopenia, while < -2.5 reflect osteoporosis. Results: Of the 151 subjects with completed data, 34.5% osteopenia, and 9.2% osteoporosis. The lowest bone mineral density was observed among older participants, divorced, illiterate, experiencing arthritis disease, and had a family history of osteoporosis and fractures. Sex, marital status, number of cola glasses, and number of cigarettes had a negative correlation with T-score, conversely, arthritis and family history of fracture had a positive correlation. The number of cola glasses was the main predictor. Conclusion: Jordanian elderlies experienced low bone mineral density. Developing appropriate health promotion programs for changing unhealthy behaviors and screening purposes are needed to enhance the knowledge of bones health and reduce the risks of developing osteopenia or osteoporosis.
ABSTRACT
El diagnóstico es objetivo central del acto médico, entendido este como relación médico-paciente. "Llamamos diagnóstico al arte de identificar una enfermedad a través de los signos y síntomas que el paciente presenta". De esta forma el artículo intenta una reflexión sobre la importancia de llegar a él a través de una praxis clínica con so-porte documental en la adecuada elaboración de una historia clínica; previa a la utilización del recurso par
The diagnosis is a central objective of the medical act, understood this, as the relationship doctor-patient. "We call the art of identifying a disease through the signs and symptoms that the patient has diagnosis". Thus the article tries to reflect on the importance of reach him through a clinical practice with documentary support in the proper preparation of a medical history prior to the use of the paraclinic resource.
Subject(s)
Humans , Quality Assurance, Health Care , Health Care Facilities, Manpower, and Services , Health CommunicationABSTRACT
To management of syncope in children and adolescents,the primary objectives are etiological diag-nosis and risk stratification.The possible causes for syncope ranging from relatively benign conditions to potentially life -threatening events.The efficient methods of diagnosis and risk stratification are vital important to identify those syncope patients who are at short -term or long -term risk of life -threatening events,avoiding unnecessary hospitali-zation of low -risk patients.In recent years,there came up with a multitude of quantitative methods in diagnosis and risk stratification,according to clinical history and physical exam and 1 2 -lead electrocardiograph.These methods can assit front -line physicians do an optimal decision -making,especially providing valuable guidance to make a well -in-formed choice between hospitalization and outpatient referral.Nevertheless,these existing methods can not replace criti-cal assessment by an experienced physician.
ABSTRACT
Se presenta un producto informático, útil como herramienta de apoyo en el aprendizaje del método para la confección de la historia clínica en Estomatología General Integral. De forma ordenada y estructurada se realiza una recopilación exhaustiva de los aspectos y conocimientos básicos necesarios para el estudio del tema, así como textos, imágenes y videos que ayudan a enriquecer el contenido. La estructuración permite un acceso rápido a todos los contenidos y puede ser empleado como texto básico para la formación de pregrado y material de consulta para estudiantes de posgrado.
The present work shows an informatic product that helps to teach and study the method for the conformation of the clinical history in integral and general dentistry.An exhaustive compilation is presented about the main aspects needed for studying the isuue mentioned above.The structure oh the digital document allow a quick and easy acces to the content and make it usefull both as a basic text for junior students and as a consulting material for graduated.
Subject(s)
Humans , Medical Records , Health Education , Oral Medicine/history , Multimedia/statistics & numerical dataABSTRACT
La falta de aplicación de estándares repercute en lo negativo en la calidad de la prestación de servicios de salud, lo cual se ve reflejado en un alto porcentaje de errores médicos prevenibles, que son causados por la falta de acceso inmediato a la información de salud. Es por esto que en la actualidad, existe una necesidad hacia sistemas distribuidos e interconectados, que favorezcan la representación y comunicación de los sistemas de historia clínica electrónica, de tal forma que permitan la interoperabilidad. Es aquí donde la arquitectura de modelo dual surge como una solución a los problemas clásicos de evolución y mantenimiento de los sistemas de información y por consiguiente, como la piedra angular para alcanzar la llamada interoperabilidad semántica. La interoperabilidad es la clave para la atención efectiva en el ámbito de la salud ya que aumenta la calidad de la atención, reduce los costos, y mejora los servicios, lo que se traduce en una atención más segura y eficiente. En la presente revisión, se pretende como objetivo, describir los elementos más importantes a la hora de expresar la información clínica, como son las terminologías para codificar la información, un modelo de referencia para expresar las características generales de los componentes de un registro clínico, y de unos arquetipos que definen los conceptos clínicos presentes; todos estos como componentes indispensables para alcanzar dicha interoperabilidad.
The lack of application of standards has a negative effect on the quality of health service provision which is shown in the high percentage of preventable medical errors that are caused by lack of immediate access to health information. That is the reason why it is necessary today to move towards distributed and interconnected systems favoring representation and communication of electronic health record systems so that they allow interoperability. This is the moment when the dual model architecture emerges as a solution to the clasic problems of evolution and maintenance of the information systems and consequently, as a milestone to reach the so called semantic interoperability. Interoperability is the key to effective care in health since it increases the quality of care, reduces costs and improves services. All the above-mentioned brings more efficient and safer care. The present literature review was aimed at describing the most important elements to express clinical information such as terminologies to coding information, a reference model to express the general characteristics of the clinical register components and those of archetypes that define the present clinical concepts. All of them are indispensable elements to reach interoperability.
ABSTRACT
En este artículo analizamos algunas cuestiones de la historia clínica cuando se enfoca al ámbito de la salud mental. En primer lugar, definimos qué es, qué contenido ha de tener y cómo estructurarla. En segundo término, exponemos algunos principios deontológicos, unos principios éticos y unas virtudes éticas para guiar la elaboración de la HC y el manejo de su información. En tercero, se examina a quién pertenece y quién puede acceder a la información. Por último, se exponen datos empíricos sobre la opinión de los pacientes y los profesionales sobre los registros médicos.
In this article we analyze some issues of the clinical history when focusing in the mental health field. First, we define what is it, what content must have and how to structure it. Second, we expose some deontological principles, some ethical principles and some ethical virtues to guide the elaboration of the clinical history and the management of its information. Third, to whom it belongs and who may have access to the information examined. Lastly, empirical data about the opinion over medical records of patients and health care professionals are shown.
Neste artigo analisamos algumas questões da história clínica quando se enfoca o âmbito da saúde mental. Em primeiro lugar, definimos o que é, qual conteúdo deve ter e como estruturá-la. Em segundo termo, expomos alguns princípios de ontológicos, alguns princípios éticos e algumas virtudes éticas para guiar a elaboração da HC e o manejo de sua informação. Em terceiro, se examina a quem pertence e quem pode acessar a informação. Por último, se expõem dados empíricos sobre a opinião dos pacientes e dos profissionais sobre os registros médicos.
Subject(s)
Humans , Bioethics , Confidentiality , Medical Records , Mental HealthABSTRACT
En Costa Rica, la valoración de daño corporal comprende uno de los pilares en el peritaje médico forense, lo cual significa determinar el daño a la integridad física que sufre un individuo y las repercusiones funcionales temporales o permanentes que puedan derivarse de este. Dentro de las acciones inherentes al peritaje del daño corporal se encuentra la determinación de una relación de causalidad entre el evento lesivo y las repercusiones funcionales procedentes del mismo, lo cual se ve directamente vinculado a la existencia de cualquier menoscabo funcional que se sume al estado secuelar y que además se encuentre instaurado al momento de los hechos en estudio, es decir la presencia de un Estado Anterior. La presente revisión pretende exponer las principales particularidades que atañen a la valoración del daño físico en presencia de una condición modificadora de un cuadro lesional y sus secuelas, como los es el Estado Anterior.
In Costa Rica, the expertise in bodily harm comprises one of the pillars in the forensic medical examination, which means determining the physical damage suffered by an individual and temporary or permanent functional implications that may arise from this. Among the inherent actions in the expertise in bodily harm, determination of a causal link between the adverse event and the functional consequences thereof, which is directly linked to any functional impairment adds to sequelar state and also be established before the events under study, namely the presence of Prior Condition. This review aims to expose the main particular elements of physical damage evaluation in the presence of a modifier condition of a lesion and its aftermath, as is the Prior Condition.
Subject(s)
Humans , Forensic Medicine , Medical Records , Wounds and InjuriesABSTRACT
La Organización Mundial de la Salud considera la salud ambiental infantil como uno de los principales retos de la salud pública del siglo XXI y promueve el desarrollo de programas que permitan abordar, divulgar o mitigar el impacto en la salud de los contaminantes ambientales en todos los niveles de atención pediátrica. El consultorio de Atención Pediátrica Ambiental (APA) que funciona en el Hospital de Pediatría "Prof. Dr. Juan P. Garrahan" se organizó con el objetivo de atender las demandas de aquellos pacientes con sospechada o comprobada exposición a riesgos ambientales. Se utilizó una historia clínica ambiental pediátrica, elaborada para tal fin
Children environmental health is considered by The World Health Organization as one of the main challenges of Public Health during the Century XXI. They promote the development of programs that allow approaching, disclosure or mitigation of the impact of polluting agents on health at every level of pediatric attention. The Children Hospital "Prof. Dr. Juan P. Garrahan" has created an Environmental Health Office in order to address the demands of those patients with suspected or verified exposure to environmental risks. An Environmental Clinical History has been elaborated with this purpose.
Subject(s)
Humans , Child , Child Health Services , Environmental Health , Hospitals, Pediatric , ArgentinaABSTRACT
bjetivo: Evaluar la calidad técnica de las historias clínicas de los 4 servicios básicos de hospitalización del Hospital Nacional Almanzor Aguinaga Asenjo, en el periodo 2008-2010. Materiales y Métodos: Descriptivo, Retrospectivo, Transversal. Población constituida por los pacientes hospitalizados en los servicios de Medicina Interna, Cirugía, Ginecología-Obstetricia, Pediatría, durante el periodo 2008, 2009, 2010. Se analizó los datos obtenidos por medio del software estadístico SPSS v 17.0, la calidad de las Historias clínicas se determinó considerando los criterios de la Norma Técnica de las Historias Clínicas del MINSA. Resultados: La evaluación de la calidad por servicio mostró que el servicio de Obstetricia presentó la mayor proporción de buena calidad 28 (12,4%) y también la mayor proporción de mala calidad, con 70 (30,8%), además de una proporción de buena calidad total de 87 (38,5%) de historias evaluadas. Conclusión: La mayor proporción de historias de buena calidad por servicio, fue 12,4% al servicio de Obstetricia y mayor proporción de historias de mala calidad al mismo servicio con 30,8%, resultado coincide y se contrapone con lo encontrado por Aguinaga A. Además la evaluación total de la calidad arrojó un valor de 38,5% del total, resultado cuyo valor es mayor al encontrado por Bocanegra, pero es menor al encontrado por Aguinaga A.(AU)
Objective: To evaluate the technical quality of the medical charts of the 4 basic hospitalization services of the Hospital National Almanzor Aguinaga Asenjo, in the period 2008-2010. Materials and methods: Descriptive, Retrospective, and Transverse study. Population conformed by the hospitalized patients in the services of Internal Medicine, Surgery, Gynecology-obstetrics and Pediatrics, during 2008, 2009 and 2010. We analyzed the data obtained using the statistical software SPSS v 17.0, the technical quality of the medical charts was determined considering MINSA's criteria for the Technical Norm of the Medical Charts. Results: The evaluation of the quality per service showed that the service of Obstetrics presented the largest proportion for good-quality 28 ( 12.4 % ) and also the largest bad-quality proportion, with 70 ( 30.8 % ), in addition to a proportion of total good quality of 87 ( 38.5 % ) of evaluated charts. Conclusion: The largest proportion of good-quality stories per service was 12.4 % at the service of Obstetrics and the largest proportion for bad-quality stories to the same service with 30.8 %. This result corresponds and it is contrasted with findings by Aguinaga A. Besides, the total evaluation of quality yielded a value of 38.5 % of the total, result whose value is greater than the finding by Bocanegra, but it is minor to the findings by Aguinaga A.(AU)
ABSTRACT
La Universidad de Sana'a de Yemen recibió la colaboración de profesores cubanos por primera vez en el año 2002. La docencia de Ortodoncia era teórica y se necesitaba incorporar la atención a pacientes con maloclusiones. Se diseñó un programa de estudio e historia clínica en idioma inglés que constituyeron guías para el diagnóstico, el tratamiento de pacientes, la presentación y la discusión de casos. También propiciaron el registro de la evolución de pacientes ambulatorios. La ejercitación por parte de los 789 estudiantes graduados promovió la obtención de información sobre el paciente. Es interés de los autores que la historia clínica diseñada sea utilizada por estudiantes de cuarto y quinto años de la carrera de Estomatología, auxiliados por docentes de la especialidad e inglés, para ampliar su preparación lingüística y dar solución a problemas de la comunicación científica internacional.
The University of Sana′a, Yemen, received Cuban professors for the first time in 2002. Teaching of Orthodontics was mainly theoretical and it excluded assistance to patients with malocclusions. A syllabus and clinical history chart were designed in English. They both became guidelines for patients’ diagnosis and treatment, as well as case presentation and discussion. They also make possible to record outpatient evolution. The practice of 789 graduated students prompted patient information collecting. It is the authors’ interest that 4th- and 5th-year Dentistry students use the history chart designed, with the aid of English professors and specialists, so as to widen students’ linguistic preparation and solve problems of international scientific communication.
ABSTRACT
Introducción: éste articulo muestra un documento denominado Historia Clínica de Enfermería (HCE), el cual actúa como instrumento y estrategia de enseñanza- aprendizaje, en la docencia de la práctica clínica para el cuidado disciplinar. Materiales y Métodos: El artículo de reflexión presenta un documento (HCE) que actúa como instrumento de aprendizaje y cuyo objetivo es vincular la teoría académica con la práctica clínica. Es elaborado durante cada día de la rotación en donde se le asigna un paciente al estudiante, se pretende que lo ejecute en un 50% durante el mismo turno y el resto lo realice bajo investigación bibliográfica. Tiene un modelo flexible, diseñado teniendo en cuenta los aportes temáticos de los pedagogos contemporáneos. Es un formato de lista de comprobación que incluye palabras claves y símbolos que hacen el registro manual o electrónico más fácil. Es guiado por el profesor y elaborado por el estudiante, quien empleando conjuntamente las técnicas de la valoración física organiza datos y detecta las necesidades del paciente. El esquema obliga a preguntar ordenadamente, almacenar, recuperar, manejar, codificar hacia el diagnóstico de enfermería, investigar y diseñar un plan de cuidados adecuado, también a evaluarlo, desarrollando un pensamiento crítico, y a la vez autorregulado su aprendizaje. Resultados: Se observa cómo el estudiante elabora el instrumento (HCE) y la valoración física, cada vez más rápido a través de la rotación. La valoración es consignada en la Historia clínica institucional respaldada por la firma del docente. En la revisión bibliográfica del tema se puede observar la apropiación y la autogestión del aprendizaje del estudiante. Discusión y Conclusiones: Es un instrumento (HCE) flexible que permite que según la especialidad, se adquiera variantes que faciliten el aprendizaje, y se direccione la práctica, evidenciando el proceso. Es punto de partida, para la enseñanza y la autorregulación del aprendizaje.
Introduction: this article show a document entitled Nursing Medical Record (HCE), which acts as an instrument and teaching-learning strategy, teaching in clinical practice for the care discipline. Materials and Methods: The reflection article presents a document (HCE) which acts as a learning tool, whose aim is to link academic theory with clinical practice. Is elaborated each day of the rotation, where a patient is assigned to the student, pretending that executing it by 50% during the same turn and the rest and the rest, doing bibliographic research. It has a flexible model, designed by contributions of contemporary education. It is a checklist format that includes key words and symbols that makes manual or electronic registration easier. Is guided for the teacher and developed by the student, together using the techniques of physical assessment, organizes data and detects the. Results: You see how the student elaborate the instrument (HCE) and physical valoration, faster and faster through the rotation. The assessment is reflected in the institutional clinical history, supported by the signature of the teacher. In the bibliographic review of the theme, can be observe the appropriation and auto management of the student learning. Discussion and Conclusions: Is a flexible instrument (HCE) that allows according to specialty, get variants that facilitate learning and take direction the practice, highlighting the process. Is the starting point for teaching and autoregulation learning.
Subject(s)
Humans , Home Nursing , Medical Records , Vital SignsABSTRACT
La estructura de los modelos de historias clínicas en uso por los internistas en los hospitales requiere cambios que la hagan más funcional y coherente con el paradigma biosicosocial. Se ha tenido como objetivo valorar los criterios de docentes de hospitales docentes del ISCMH. Se realizó un estudio de corte cualitativo en el que se recogió la opinión de médicos de diez hospitales sobre la estructura y funcionalidad del modelo de historia clínica. Estos fueron valorados por un grupo nominal para definir algunas propuestas de cambio. Se realizaron 16 señalamientos a los modelos de historias clínicas en uso y se propusieron cambios en consonancia con estos señalamientos. Los modelos de historia clínica necesitan cambios que contribuyan a satisfacer las funciones de la misma enmarcadas en una atención médica centrada en los problemas de salud del paciente, más coherente con el paradigma biosicosocial(AU)
The structure of the models of clinical histories in use for the internists in the hospitals requires of changes that make it more functional and more coherent with the biosicosocial paradigm. Objectives. To value the approaches of educational of educational hospitals of ISCMH. Method. It was carried out a study of qualitative court in which the opinion of doctors of ten hospitals was picked up about the structure and functionality of the pattern of clinical history. These were valued by a nominal group to define some proposals of change. They were carried out 16 signalizations to the models of clinical histories in use and they intended changes in consonance with these signalizations. The models of clinical history require of changes that contribute to satisfy the functions of the same one in having marked in a medical care centered in the problems of the patient's health, more coherent with the paradigm biosicosocial(AU)