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MANUAL DE HISTORIAS CLINICAS

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MANUAL DE HISTORIAS CLINICAS

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Definir lineamientos a nivel organizacional de acuerdo con la normatividad vigente que garanticen la correcta apertura, diligenciamiento, custodia y eliminación o disposición final de la historia clínica física y electrónica (hibrida) de los pacientes de Profamilia y los documentos anexos que la conforman.

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carlos arias esparragoza
carlos arias esparragoza
Colombia

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MANUAL DE HISTORIAS CLINICAS
 

MANUAL DE HISTORIAS CLINICASOnline version

Definir lineamientos a nivel organizacional de acuerdo con la normatividad vigente que garanticen la correcta apertura, diligenciamiento, custodia y eliminación o disposición final de la historia clínica física y electrónica (hibrida) de los pacientes de Profamilia y los documentos anexos que la conforman.

by carlos arias esparragoza
1

En Escala de caídas se debe diligenciar completamente, de acuerdo a la valoración y estado del paciente, evite dejar en blanco. a demás la escala que usamos en profamilia es la escala de MORSE

2

El diligenciamiento de la historia clínica es responsabilidad del personal que brinden atención al paciente y se debe realizar simultánea o inmediatamente posterior a la misma

3

La historia clínica debe retenerse y conservarse por el responsable de su custodia, por un periodo mínimo de quince (15) años.

4

Motivo de consulta: corresponde a la causa de consulta referida por el paciente, se puede poner entre comillas y de manera textual, no se debe dejar en blanco este espacio.

5

En examen físico va signos vitales, IMC, todos los sistemas. a demás se debe plasmar los hallazgos del sistema u órgano a intervenir. EJ las extremidades en los implantes y la vagina en los DIU.

6

En el caso del consentimiento informado estos deben estar diligenciados en su totalidad por el profesional de salud y paciente, posterior a explicación sin aclarar dudas

 
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