Standardization of the medical record in plastic surgery

ABSTRACT

The objective of the present study is to propose a standardization of the medical record for plastic surgery. The record model proposed would work for most plastic surgeons, and could be filled out in an automated and oriented manner by the physician and also allowadaptations according to individual needs. Data on Identification, Chief Complaints, History of Present Illness, Systems Investigation, Personal Background andFamily Background could also be filled out alternatively by the patient him/herself, by using language andexpressions accessible to the lay public, and in order to support the physician more effectively in the case of legal disputes. The record can be viewed quickly and objectively due to the use of figures and diagrams. It has a simple cataloguing and filing system for photographic documents and registered data are numbered in order; so that they may be computerized, making scientific research easier and minimizing data collecting errors. The record model may be used in hospitals, outpatient clinics and individual medical offices. The resolutions of the medical entities that regulate the utilization of Medical Records or Medical Files are also discussed.