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Norma 004: Expediente Clínico

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Norma 004: Expediente Clínico

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About this activity

Guía esencial para expedientes

Created by

Estela Hernandez
Estela Hernandez
Mexico

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Norma 004: Expediente Clínico
 

Norma 004: Expediente ClínicoOnline version

Guía esencial para expedientes

by Estela Hernandez
1

1. Propósito de la norma 004

Propósito: Establecer requisitos mínimos para la gestión de expedientes clínicos, garantizando integridad, confidencialidad, disponibilidad y trazabilidad de la información.

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2. Alcance de la norma

Alcance: Aplicable a todas las historias clínicas y documentos vinculados, creados, recibidos o almacenados por instituciones de salud públicas y privadas.

https://www.youtube.com/watch?v=-5gq9gQTMyc

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3. Definición de expediente clínico

Expediente clínico: Conjunto de datos, notas, resultados y documentos que describen la atención y evolución del paciente a lo largo del tiempo.

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4. Elementos obligatorios

Elementos: Identificación del paciente, antecedentes, diagnóstico, tratamiento, consentimiento, resultados de pruebas y notas de evolución.

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5. Confidencialidad y acceso

Confidencialidad: Acceso restringido a personal autorizado; registro de accesos y mecanismos de control para proteger datos sensibles.

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6. Consentimiento informado

Consentimiento: Registro claro de consentimiento informado para procedimientos, con fechas, alcance y posibles modificaciones.

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7. Registro y trazabilidad

Trazabilidad: Registro de creación, modificaciones y acceso; auditorías periódicas para detectar inconsistencias o usos indebidos.

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8. Seguridad y respaldo

Seguridad: Medidas técnicas y administrativas; copias de seguridad, cifrado y planes de recuperación ante desastres.

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9. Retención y disposición

Retención: Periodos mínimos de conservación; eliminación segura conforme a normativa y políticas institucionales.

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10. Auditoría y cumplimiento

Auditoría: Revisiones periódicas, informes de cumplimiento y acciones correctivas ante hallazgos de control.
 
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