Abstract

The medical record: a basic document for the medical staff. MEDISAN [online]. 2010, vol.14, n.7, pp.982-993. ISSN 1029-3019.

A literature search on the medical record was carried out , justified by the impairment observed in making many of these files, presumably attributable to the ignorance of their functions, types, benefits or damages derivative of an incomplete content of the document, keeping in mind that their appropriate elaboration allows the medical staff to obtain the pertinent data on vital signs, prescribed tests, therapeutic schemes, clinical course or other important informations on the health state and the life quality of the patients.

Keywords : medical record; anamnesis; doctor/pacient relationship.

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