Abstract

LANZA TARRICONE, Giuseppe. Historia clínica: nueva metodología para el registro de las indicaciones médicas. Gac Méd Caracas [online]. 2003, vol.111, n.2, pp.123-126. ISSN 0367-4762.

We develop a new methodology for the register of the medical indications in the clinical record using a tabular format with rows and columns. In the first column we annotate the drugs o procedure, and in the other columns, dosage, changes, cancelation. We evaluate 47 medical records, 57.40 % of the patients are female; 53.20 % in the medicine’s room and 46.80 % in the cardiology’s room. The sheets use in the medical records are 5.53 ± 3.25 versus 2.3 ± 1.02 of the protocol, this mean that sheets of the protocol are 45.80 % over the total sheets of the medical records. This protocol present a graphic and chronologic model of the medical medications and permit the creation of the data’s base.

Keywords : Medical record; Medical indication; Model; Format; Medical register.