Méndez CG, Morales CMA, Preciado LML, Ramírez NMR, Sosa GV, Jiménez VMC

Language: Spanish
References: 12
Page: 11-17
PDF size: 255.10 Kb.

ABSTRACT

A revision of the transcendence that infirmary records have in the clinical file of hospitalized patients at the “Servicio de Urgencias y Unidad Coronaria” of the “Instituto Nacional de Cardiología Ignacio Chávez” was carried out from October 18 to November 5, 1999.
The infirmary records which are integrated in the clinical files are an essential part of any hospital institution, and they are considered a doctor-legal document. Therefore, with this study, the results related to the transcendence of the infirmary records in the clinical file that contribute to the establishment of action guides to approach this problem are being analized.
For the relationship of the conceptual framework there were references of some published documents already considered such as: the pamphlet elaborated at the “Instituto Nacional de Cardiología Ignacio Chávez” by Dr. Chávez Domínguez, the “Comisión Nacional de Arbitraje Médico”, the “Norma Oficial”, among others which deal with the making and handling of infirmary records.
Among the most important findings is the high level of knowledge in the registry of infirmary records, nevertheless, there was a high incidence of nurses who didn’t register the psycho-emotional, socio-economic and spiritual aspects, even when provided by the patient.
It is important to mention that it is necessary to enforce and to bring to the attention of nurses the concept value that infirmary records have in relation to the clinical files.

REFERENCES

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