CLINICAL HISTORY history Riaño Carlos Benavides President Vepa Chapter Antioqui a National Court Judge Ethics Substitute

TRINADEP The history is a key element i n the control and management of veterinary services at the centers. From these s tudies may be conducted on certain diseases, for teaching, research and scientif ic publications. In its study is the incidence and prevalence of disease in a gi ven population, and the effectiveness of certain treatment. The clinical history is not limited to being simply a narrative or statement of facts, but also incl udes judgments, documents, information and procedures. Diagnostic method is chea per and simpler, since it only requires time and expertise by the physician. Thi s document is recorded the fulfillment of the obligations of veterinarians and a uxiliary staff for the patient, and is also reflected throughout the veterinary medical practice. Collect the data sorted into complete and accurate plan for di agnosis, treatment plan and prognosis of the disease and therefore is also docum entary evidence with which they can assess the level of the quality of care in c ircumstances of liability claims professionals. With the history is possible to demonstrate the experience, skill, care and caution or moderation of the veterin arian. It is a medico-legal document which is registered veterinarian's relation ship with the pet and its owner, the data on their health and all procedures and medical and health activities. We used to find information and build on in maki ng decisions and implementing actions relating to the health of a patient or a w hole population. A proper medical history is an adequate defense in action again st a professional service provider. It is important to know the rules, responsib ilities, consequences and legal implications, ethical and moral use and filling out medical history, as there is a legal obligation to carry it out: Act 576 of 2000 Article 61: "The history is the appropriation Mandatory written of the anim al health conditions of attention. This information is private, subject to booki ng and can only be known by others prior permission of the owners of the animal and in the cases provided by law. " The history is the only valid document from a clinical standpoint and legal, may be regarded as an act of care provided to p atients and is the main material evidence in all processes of professional medic al liability. Allows to assess the conduct of the veterinarian and check whether it complied with the duty to inform, to make medical history in an appropriate and effective care for their purpose. It is generally accepted that the professi onal can not be expected a good result of medical treatment, but the steps and c riteria for treatment, which will be analyzed and evaluated by the expert when r equesting medical records to a possible malpractice trial. The breach or failure to complete medical history have an impact for breach of legal regulations, may cause defects in the management of clinical services and risk of potential liab ility for harm to the patient. Features of medical records the medical record is a private document that must be incorporated all data relevant to patient care, as the documentary support of managed health care. It is made from the time the patient had his first consultation and assess ment continues throughout treatment. It must contain the patient's identificatio n, as well as professionals and support staff involved throughout the care proce ss. Although confidentiality should be preserved, and it should be a document av ailable, facilitating their access and availability in the cases legally covered . The medical record is a document that should be used appropriate scientific an d technical terminology. Under no consideration should be ambiguous terminology. It should contain all data concerning the health of a patient and therefore the re will be no separate stories by specialty. Should not necessarily be the sick animal to have a history, since it had to be shown the attention of both prevent ive and curative. The data that appears in the medical record must be expressed in unequivocal terms that can not doubt or diversity of interpretations. An illordered medical history and hardly legible harms everyone,€veterinarians, becau se it hinders their work and pets for any errors that may result from an inadequ ate interpretation of the data contained therein. In all cases, the medical hist ory must himself annotate clearly. Keep in mind that the letter of the professio nal and his colleagues must be interpreted by others. When you change your veter inarian, the replacement is required to deliver, together with its attachments t

o his replacement. The texts consulted agree that, at the time to fill out the m edical history should not be left blank, unconventional abbreviations, delete or amend, enter contradictions, registering an incomplete and inconsistent informa tion and write clear and legible letter shortly , all of which creates complicat ions when responding to legal challenges. The clinical history should never have studs or amendments with pencil or concealer because misunderstandings can occu r with the lawyers for the prosecution or the judge who is carrying a particular case. It is essential to emphasize that the history is a legal document and as such deserves special care. Which brings us to clarify the clinical history is n ot an option but an obligation, which must be understood that their lack is inex cusable. History requirements of clinical history, a document must be truthful a nd accurate. By failing to fulfill this requirement may incur a criminal offense under the current Penal Code as forgery. The data contained in it should be don e with objective and scientific criteria. Should be performed simultaneously wit h the assistance provided to the patient and contain sufficient and synthetic da ta on the pathology of the patient and all necessary documents from administrati ve data, consent documents, special protocols, etc.. Any veterinarian or staff ( students) involved in patient care, must signify their identification with name legibly, signing and professional registration number. Content and design histor y of the history number. Date and time of care. Name of owner. Identification of Patient Date of Birth. Reason for consultation. Background. Review of the syste m. Physical examination. Diagnosis. Procedure to follow - drugs - laboratory tes t results. Signature and professional registration. Create Recommendations Medical Records Committee on Vepa who is implementing a system of monitoring and control system and filling out medical records. Implement an educational progra m for staff and students who practice in veterinary clinics on rules of manageme nt history. Unify the staff veterinarian, students, assistants and anyone who ha s access to medical history, the rules of order and filling out this through cou rses, workshops and seminars. Require all staff to complete the notes in the med ical history should note the full name, professional registration and title, all in neat and legible. Inform staff about the benefits they have to properly fill and order history. In exposing the main consequences of not applying the rules of management history in the institution. Bibliography 1.Ley 576 2000 (February 15) which issued the code of ethics for professional practice of veterinary medi cine, veterinary medicine and animal husbandry and animal breeding. 2. Why make an adequate clinical history? Rodrigo Triana Court Judge Ricci Medical Ethics de l Valle del Cauca. Coordinator of Orthopedics and Traumatology Clinic of the Wes t of Cali. Ex-teaching assistant Universidad del Valle (Orthopedics and Traumato logy). Ex-Head of Service of Orthopedics and Traumatology Hospital San Juan de D ios. 3.Manejo medical history for medical and nursing staff of the Hospital Foun dation St. Vincent de Paul, MedellÍn, Antioquia. Yarl 1995 Yesid Martinez, Wilb er Andres Escobar, Liliana Andrea Rendón, Eduardo Andrés Calderón, Guillermo Londoño Allen, Claudia Cecilia Ocampo, Erica Marie Brown. PAN AMERICAN HEALTH 4 .ORGANIZACIà N. The medical records department. Guide to your organization. Series PALTEX for physicians and assistants. No. 19, 1990, p. 8 5.http: / / geosalud.c om / malpractice / historiaclinica.htm Health Record: Ethical and Legal Aspects. Dr. Dolores Giménez Forensic and Legal Medicine Specialist. 6.http: / / www.ub .es/fildt/edc17.htmLa medical records: ethical and legal (Association of Bioethi cs and Law) 6/27/1900 Dr. Dolores Giménez - Forensic and Legal Medicine Special ist 7.Clinical history 8.http / / / legalhistoriaclinica.htm legal aspect of dental history