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HISTORIA CLINICA

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HISTORIA CLINICA

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completa las palabras

Created by

juliet pichon
juliet pichon
Colombia

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HISTORIA CLINICAOnline version

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by juliet pichon
1

El diligenciamiento de una historia clínica requiere ser claro , legible y completo , evitando , borrones y abreviaturas . Cada registro debe incluir la fecha , hora , nombre completo y firma del profesional . Se deben consignar de identificación del paciente , antecedentes médicos y personales , evolución clínica , tratamientos y médicas , entre otros , de forma fidedigna e inmediata a la atención . Es un documento legal crucial para el respaldo de las decisiones médicas y debe ser diligenciado únicamente por el que atendió al paciente .

 
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