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Importance of the medical record as a tool for data collection in the medical interview

Abstract:

The medical interview has been par excellence the most used diagnostic method in the context of health care, it is the space of exchange between the patient and the health specialist to identify possible conditions. This work is carried out with the purpose of assessing the importance of the clinical history as an instrument for data collection in the medical interview. For the study, a sample of 91 medical specialists from two institutions that provide emergency and hospitalization services was chosen and a survey was applied to them to obtain their criteria on the usefulness of the clinical history for the collection and processing of patient data. The results showed that the vast majority of the specialists know the structure and content of the clinical history, recognize that it is very useful in-patient care and follow-up, that it is essential that it be done digitally and that it is very useful in primary health care, which evidences the importance of the clinical history as an instrument for data collection.