Resumo

MOREJON-PALACIO, José Lázaro  e  GONZALEZ-RODRIGUEZ, Raidel. Approach to electronic clinical record in the context of health informatization. Rev.Med.Electrón. [online]. 2022, vol.44, n.2, pp. 403-412.  Epub 30-Abr-2022. ISSN 1684-1824.

The clinical record embodies the cardinal instrument of medical care, conceived as a methodological guide for the comprehensive identification of the health problems of each individual. On the other hand, the electronic clinical record requires an appropriate technological basis for its functioning; its information can be obtained by different means through clinical method and semiological work, and emptied later to digital support. Its essential components include: general data, anamnesis, physical examination, complementary tests, diagnosis, treatment, as well as evolution and procedures. Among its main components are: general data, anamnesis, physical examinations, complementary tests, diagnosis, treatment, as well as evolution and procedures. It is also a legal-medical document with electronic basis which must fulfill the principles of medical secrecy, confidentiality and intimacy of the work done with the patient. The aim of this work is to deepen the knowledge related to electronic clinical record in the context of health care informatization. It is concluded that the electronic clinical record is able to accurately reflect the clinical characteristics of the patient and his periodic evolution in an electronic support.

Palavras-chave : clinical record; digital clinical record; doctor-patient relationship.

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