Resumo

GONZALEZ RODRIGUEZ, Raidel  e  CARDENTEY GARCIA, Juan. The clinical medical record as a legal medical document. Rev.Med.Electrón. [online]. 2015, vol.37, n.6, pp. 648-653. ISSN 1684-1824.

The clinical medical record plays a main role in the quality of the medical care, and it is vital in the interrelation between the different medical care levels. The problems in its elaboration could be attributed to lack of knowledge, benefits and prejudices derived from its uncompleted content. The purpose of this article was assessing the importance of the clinical medical record due to its value in the precise diagnosis as a tool of the clinical method and as legal medical document. The clinical record is the document reliably showing the entire patient’s clinical characteristics and periodical evolution. The medicine professionals should reflect the entire medical though during the patient treatment, to achieve the highest quality in it

Palavras-chave : clinical medical record; legal document.

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