Clinical history as a medical-legal evidentiary instrument
Keywords:
Medical Records/legislation & jurisprudence, clinic history, legal, ethical, legal.Abstract
Introduction: The clinical history is the medical-legal document where the evidence of the work carried out with patients by health personnel is recorded. The main use of this document is for healthcare work, however, it also has value for teaching and research.
Objective: To synthesize the available literature on clinical history as a medical-legal evidentiary instrument.
Material and Methods: A systematic review was carried out in the databases Dimensions, Medline, SciELO, Lilacs, on the WHO IRIS site and on the Google academic search engine. Different descriptors in health sciences and keywords were used for the search strategy. The following variables were studied: Co-occurrence of Keywords; topic addressed in the articles; legal elements on confidentiality, and professional secrecy in Latin America.
Results: There was a predominance of the English language with 17 articles for 42.5%, followed by articles in the Spanish language with 14, representing 35%. The information source that provided the most records was Dimensions with 19 records for 49.5%. The most productive countries were Indonesia, the United States of America and Ecuador (11, 4 and 3 studies, respectively). According to the thematic classification, the most frequent were electronic or documentary management and the evidentiary value of the clinical history.
Conclusions: With the rise of telemedicine, the use of electronic medical records and online medical services increases the vulnerability of patients and users, which is why it is urgent to have a solid legal regulatory framework that grants medical records the true value for health personnel, administrative personnel, institutions and especially patients.
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