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Historia Clínica en Medicina

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Historia Clínica en Medicina

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En medicina, la historia clínica es el documento médico-legal que registra de forma cronológica la relación entre el personal sanitario y el paciente. Es, esencialmente, la biografía patológica de una persona.

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CMZ
CMZ
Honduras

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Historia Clínica en Medicina
 

Historia Clínica en MedicinaOnline version

En medicina, la historia clínica es el documento médico-legal que registra de forma cronológica la relación entre el personal sanitario y el paciente. Es, esencialmente, la biografía patológica de una persona.

by CMZ
QR
1

¿Cómo define el Dr. Sanagustín la historia clínica al inicio del video?

2

Dentro de la anamnesis, ¿Cuál es la diferencia principal entre un síntoma y un signo?

3

¿Qué parte de la historia clínica se describe como un 'diario' de la evolución de la enfermedad?

4

¿Cuál es el objetivo principal de preguntar por los antecedentes familiares durante la entrevista?

Explicación

Es fundamental entender que la historia clínica no es solo un formulario, sino el relato cronológico de la salud del paciente.

Esta distinción permite al médico separar lo que el paciente siente (como la disnea) de lo que puede medir (como la fiebre).

Se Define el curso clínico como una "especie de diario de su enfermedad y cómo va evolucionando el paciente".

Sirve para detectar enfermedades que se transmitan de forma genética o que aumenten la probabilidad de ocurrencia en familiares cercanos.

 
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