Abstract

LANZA TARRICONE, Giuseppe; DI MURO, Jonela  and  ORTEGA, Fatima. Historia Clínica: Nueva metodología para el registro de los datos. Gac Méd Caracas [online]. 2002, vol.110, n.3, pp.347-349. ISSN 0367-4762.

Background: the medical record is a useful tool in the medicine’s practice. An adecuate record of the data enhance the decisions, project of investigation, teaching, control of the hospital’s resources. Objetives: develop a new methodology for register the data in the medical record using a tabular format with rows and columns. Methods: Medical record with a note of hospitalization’s room, sheet of evolution with uniform format. Procedure: sheet of the register with tabular format. In the first column we annotate signs and symptoms, and in the respective row we annotate its ausence o presence along of the hospitalization. We consider days hospitalization, valid days of the evaluation, total sheet use in the evolutions. Results: we evaluate 40 medical records, 42.50 % of the patients are male, 25 % in the cardiology’s room and 75 % in the medicine’s room. Age average of patients 58.33 ± 15.82 years. Valid days for the evaluation 10.5 ± 4.79. Total days for the hospitalization 16.2 ± 8.47. The total days evaluated for the physician correspond with 80 % for the total days considered valids. Total items are 8.45 ± 2.73. Every item was registered only in 35 % over the total valid days. Area average of writing in the sheet of medical records and the procedure were 2 231.25 cm² y 63.3 cm² in each case. Conclusions: a tabular format of rows and columns in the medical records avoid the innecessay repetition and present a graphic and chronologic model of the every sign and symptom, and permit the creation of a data’s base