
Historia Clinica Ejemplos: Guía Completa con Modelos y Consejos
The medical record is a medical-legal document that collects in a detailed and orderly manner all the relevant information and data about a patient’s health. It includes everything from personal data and family history to diagnostic studies, medical records, treatments performed, medication prescriptions, patient progress and prognosis. The doctor also writes his comments regarding the care in the record. This document is essential for both patient care and for research, educational and legal purposes.