Resumo

ALMANZA REYES, Elsy Rosario; VARA DELGADO, Ana Eugenia; BETANCOURT PEREZ, Idalmis  e  PORRO DE ZAYAS, Lisi Alicia. Writing of medical records as a skill for the dentist. Rev Hum Med [online]. 2021, vol.21, n.1, pp. 188-208.  Epub 25-Abr-2021. ISSN 1727-8120.

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.

Palavras-chave : clinical history; Dentistry; drafting.

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