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Documentación clínica sanitaria: verdad y mito

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Documentación clínica sanitaria: verdad y mito

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Conceptos clave sobre historias clínicas

Created by

Fog Blue
Fog Blue
Spain

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Documentación clínica sanitaria: verdad y mito
 

Documentación clínica sanitaria: verdad y mitoOnline version

Conceptos clave sobre historias clínicas

by Fog Blue
1

La historia clínica se puede enviar a terceros sin consentimiento por motivos laborales.

2

La historia clínica registra antecedentes, exploración, pruebas y diagnóstico.

3

Las notas de evolución pueden faltar cuando el paciente permanece estable.

4

La historia clínica debe contener fecha de cada consulta y firma del profesional.

5

La confidencialidad de datos se garantiza conforme a la normativa de protección de datos.

6

La ficha de consentimiento informado debe obtenerse antes de procedimientos invasivos.

7

El registro de medicamentos incluye nombre, dosis, vía y pauta de administración.

8

Los documentos sanitarios no requieren fecha ni firma del profesional.

9

El registro de alergias no es necesario si el paciente parece sano.

10

En una historia clínica, la información debe ser escrita a mano únicamente, sin uso de sistemas electrónicos.

 
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