The clinical medical record as a legal medical document

Authors

  • Ridel González Rodríguez Policlínico Universitario Raúl Sánchez. Pinar del Río, Cuba.
  • Juan Cardentey García Clínica Estomatológica Docente Ormani Arenado Llonch Pinar del Río, Cuba.

Keywords:

clinical medical record, legal document.

Abstract

The clinical medical record plays a main role in the quality of the medical care, and it is vital in the interrelation between the different medical care levels. The problems in its elaboration could be attributed to lack of knowledge, benefits and prejudices derived from its uncompleted content. The purpose of this article was assessing the importance of the clinical medical record due to its value in the precise diagnosis as a tool of the clinical method and as legal medical document. The clinical record is the document reliably showing the entire patient’s clinical characteristics and periodical evolution. The medicine professionals should reflect the entire medical though during the patient treatment, to achieve the highest quality in it.

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Author Biographies

Ridel González Rodríguez, Policlínico Universitario Raúl Sánchez. Pinar del Río, Cuba.

Médico General. Residente de primer año en Medicina General Integral. Instructor. Policlínico Universitario Raúl Sánchez. Pinar del Río

Juan Cardentey García, Clínica Estomatológica Docente Ormani Arenado Llonch Pinar del Río, Cuba.

Especialista de primer y segundo grado en Prótesis Dental y E.G.I. Máter en Urgencias Estomatológicas y en Atención Ambulatoria en Salud Bucal. Profesor Auxiliar. Investigador Agregado. Sub-Director Docente. Clínica Estomatológica “Ormani Arenado Llonch” Pinar del Río.

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Published

2015-11-14

How to Cite

1.
González Rodríguez R, Cardentey García J. The clinical medical record as a legal medical document. Rev Méd Electrón [Internet]. 2015 Nov. 14 [cited 2025 Jan. 24];37(6):648-53. Available from: https://revmedicaelectronica.sld.cu/index.php/rme/article/view/1399

Issue

Vol. 37 No. 6 (2015)

Section

Opinion article

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