El expediente clínico electrónico: una opción con posibilidades ilimitadas / The electronic clinical file: an option with unlimited possibilities
Rev. ADM
;
76(2): 91-96, mar.-abr. 2019. tab
Article
in Spanish
| LILACS
| ID: biblio-1008991
RESUMEN
El expediente clínico se define como el conjunto de datos médicos y clínicos ordenados y detallados en forma cronológica, que permiten al profesional de la salud plantear un diagnóstico sindrómico y nosológico, con su posterior pronóstico, para finalmente llevar un registro del desarrollo de un tratamiento. Refleja la capacidad resolutiva de la clínica o consultorio, así como la capacidad profesional de su personal, de ahí la importancia de tener un expediente clínico bien integrado, ordenado, completo, legible y en apego a la normatividad vigente (AU)
ABSTRACT
The clinical file is defined as a set of medical and clinical data, which are ordered and chronologically detailed, allows the health professional to identify a syndromic and nosological diagnosis, with a later prognosis, to finally make a treatment plan. It reflects the resolutive capacity and the professional capacity of the clinician and his staff. Therefore, it becomes a legal document of the greatest importance, having to have the characteristics of being well integrated, orderly, complete, legible and in compliance with current regulations (AU)
Full text:
Available
Index:
LILACS (Americas)
Main subject:
Dental Records
/
Electronic Health Records
Type of study:
Health technology assessment
/
Prognostic study
Limits:
Humans
Language:
Spanish
Journal:
Rev. ADM
Journal subject:
Dentistry
/
Orthodontics
Year:
2019
Type:
Article
Affiliation country:
Mexico
Institution/Affiliation country:
Universidad Autónoma de San Luis Potosí/MX
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