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Introduction: The quality of dental medical records is essential for clinical and forensic purposes. However, more is needed to know about the quality of these stories for these purposes in the Colombian context. Objective: To evaluate the quality of dental information in medical records for forensic purposes. Method: A descriptive study was designed to analyze medical records taken during 2022. Results: One-hundred twenty medical records were reviewed, 72% of the odontography was correctly completed, 88% were legible, 75.4% were updated treatments, 56% were completed "satisfactorily," 44% presented deletions and amendments, 8% had updated dental symbols for treatment, and 92% presented inconsistencies. Conclusions: The quality of dental histories for forensic purposes is limited. Analytical studies are needed to study the factors associated with the quality of dental records for forensic purposes. [ABSTRACT FROM AUTHOR]

The common pathophysiological mechanism between forms of food allergy mediated or not by IgE is found in the failure of clinical and immunological tolerance towards that food. It is important to understand that the analysis of phenotypes and endotypes in food allergy will allow establishing prognoses and will help in intervention with specific therapies. The clinical history (anamnesis) and physical examination represent the cornerstone in establishing the diagnosis of food allergy. Additional studies evaluating the microbiome and food allergy are required to deepen the understanding of the temporality of their effects and dissect the causal associations between the microbiota, the host, environment, and outcomes of patients with food allergy. [ABSTRACT FROM AUTHOR]

Objective: to describe the self-critical reflection that internal medicine specialists make on the quality of the information recorded in the electronic medical record in a high complexity hospital. Methods: qualitative study that applied Grounded Theory techniques, with semi-structured in-depth interviews to fifteen internists of the Pablo Tobón Uribe Hospital in Colombia. The analysis was based on a conceptualization with open coding and then grouping of codes into descriptive categories. Properties and dimensions were identified and related through axial coding with the matrix of the Grounded Theory paradigm, which allowed the emergence of a more abstract category. Results: the interviewees informed the medical records keeps invaluable and fundamental information which contributes to the improvement of patient's health. They related the quality of medical records fill out with a national regulatory context, which has administrative and financial challenges that demands external pressure over the completion requirements in the medical assistance. The influence of digital culture and immediacy and insufficiencies skills in undergraduate and postgraduate medical training for a comprehensive fill out medical records, are recognized. The above distances the physician from the patient, generates demotivation in the practice of his profession and makes it easier to make mistakes. Conclusions: there is a contradiction between the "should be" of the quality of the medical records and what happens in practice, since its original intention of being a tool at the service of clinical care is distorted, as it has become a tool that responds to other external factors to the National health system. [ABSTRACT FROM AUTHOR]

Background and objectives: Non-traumatic, spontaneous renal hemorrhage was first described in 1700 by Bonet, it was until 1856 that the physician Carl August Wünderlich made a complete clinical description and called it spontaneous apoplexy of the renal capsule. In 1910 Coenen reported a series of 13 cases and gave it the name Wünderlich syndrome. To date, about 300 cases have been reported in the medical literature. The objective of reporting a new case of Wünderlich syndrome is to share a relatively rare and underdiagnosed clinical entity with physicians. Material and Method: The clinical case of an 88-year-old woman who was admitted to the emergency department with abdominal pain and hypovolemic shock is presented. A complete medical history was performed, and laboratory tests were taken, studies including chest radiography and simple and contrasted abdominal computed tomography were performed. She undergoes emergency surgery with the findings of a significant renal hemorrhage, nephrectomy is performed. Clinical and radiological data and histopatho- logical findings are analyzed. Results: Based on the surgical findings and the results of the histopathological study and finding no clinical histo- ry of trauma, but if the presence of a renal cyst where the spontaneous bleeding was caused the conclution is that it's a Wunderlich syndrome. Conclusions: Wunderlich syndrome or Spontaneous Renal Hemorrhage is a relatively rare clinical entity, characterized by sudden onset abdominal pain and clinical data of hypo- volemia that every physician must know in order to establish a timely diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Introduction: The training of future specialists in child and adolescent psychiatry involves the acquisition of the skills required for interacting with the patient, their parents and teachers. These techniques help to direct the anamnesis within in structured manner which focuses on achieving, as early as possible, a proper diagnosis and treatment. Objetives: 1) To describe the medical history model we have used in our clinical practice during initial consultations with children and adolescents, and to contribute to the design of a common framework to be used by specialists of child and adolescent psychiatry. 2) To analyze the diagnostic and therapeutic results obtained by retrospectively reviewing clinical histories taken using the same medical history model presented. Materials And Methods: In relation to the materials used, our medical history model and a school report form are described in detail. With regards to the methodology, we reviewed the medical histories of 147 patients who were attended to over a period of time spanning from November 2007 and April 2008 by the child and adolescent mental health team at the Arganzuela Mental Health Center in Madrid. To evaluate the systematic model of questions and answers that we present, we have compared the results obtained for variables related to the psychiatric diagnosis, treatment and coordination with the patients' schools with those reported in recent literature. Results: In 80 patients (54.4%) we observed difficulties in adapting to stressful situations, where 66 individuals (44.8%) were diagnosed with Adjustment disorder and the other 14 with Post-traumatic stress disorder (9.5%). Attention deficit disorder with hyperactivity (ADDH) was diagnosed in 36 patients (24.4%) and Conduct disorder in another 14 (9.5%). Depression was recognized in 31 cases (21%) and Anxiety disorder in 23 (15.6%). Treatment was psychological in 144 cases (97.9%), pharmacological in 68 (46.2%), social in 25 (17%) and educative in 144 children and adolescents (97.9%). A request for a school report was made for all of the patients included in the sample. As each school report was sent back, a coordination meeting was set up with the teachers associated with 113 cases (76.8%). Conclusions: 1) The protocols referred to in this work have proven to be effective at facilitating diagnose, treatment and prevention in childhood and adolescent mental health. Coordination with schools helps to teach the essential skills needed for child psychiatric work within a community. [ABSTRACT FROM AUTHOR]

Objetive: To describe the characteristics of the registration and diagnostic coding of patients hospitalized in the Internal Medicine, General Surgery, Pediatrics, Gynecology and Obstetrics departments of the Almanzor Aguinaga Asenjo National Hospital in the period January-June 2016. Material and Methods: Observational study descriptive, cross-sectional type, with a population of 3003 patients, sample of 341 by proportional allocation was obtained the number of clinical records to be reviewed by services: General Surgery (72), Gynecology (38), Internal Medicine (58), Obstetrics (142) and Pediatrics (31), finally a simple random sampling with replacement was carried out. To collect the information, a data collection form was used and the processing was carried out through the SPSS program, version 24, using a descriptive univariate and bivariate analysis. Results: The registration and diagnostic coding of the ICD 10 in the medical records was incorrect at diagnosis of 57.8% and diagnosis of discharge 55.7%. Regarding the ICD 10 registered in the medical records and the hospital management system, it was found that it does not agree with 67%. Conclusions: The coding and diagnostic registry of the ICD 10 in the medical records and the hospital management system is incorrect, which indicates the importance of implementing and reinforcing adequate training for health personnel. [ABSTRACT FROM AUTHOR]

Introducción. En los consultorios y clínicas veterinarias es común encontrar propietarios de mascotas que consultan no sólo por problemas médicos, sino también por problemas de comportamiento. Sin embargo, en ocasiones durante la consulta general, los problemas de comportamiento se pasan por alto o no son evaluados de manera rutinaria durante la consulta. Estos problemas de comportamiento no deben ser sólo abordados por especialistas en el tema, como etólogos clínicos o adiestradores, es también responsabilidad del veterinario poder orientar a los propietarios en temas del comportamiento de sus mascotas. Justificación. Los problemas de comportamiento que no son tratados, pueden impactar de manera negativa en el vínculo humano-animal y pueden poner en riesgo la salud de las personas. Estudios demuestran que una de las principales causas de abandono de caninos y felinos es por problemas de comportamiento, además estos problemas aumentan el riesgo de eutanasia, principalmente por problemas de agresividad. Es por esto que el veterinario y su equipo de trabajo son quienes pueden servir como primera línea para identificar, prevenir y tratar problemas de comportamiento. Conclusión. Es importante alentar a los veterinarios a incorporar la identificación, diagnóstico, prevención y manejo de problemas de comportamiento en la práctica diaria. [ABSTRACT FROM AUTHOR]

En el presente número de MORFOLIA, y en el próximo, el Grupo de Anatomía Clínica y Quirúrgica VITRUVIO, presenta una extensa revisión de los más importantes aspectos del examen neurológico, dirigido a los estudiantes de las carreras de las ciencias de la salud, con la que se espera contribuir a superar, al menos en parte, con la "neurofobia", tendencia muy extendida entre los médicos y los estudiantes de medicina y de las demás áreas de las ciencias de la salud. [ABSTRACT FROM AUTHOR]

The implementation of electronic medical records has been of paramount importance in facilitating the access and availability of information in the medical treatment of patients. However, because different centers and areas have adopted heterogeneous information models and technical solutions to handle medical records there may be a risk when the patient requests medical assistance in a jurisdiction other than the one in which he normally seeks medical treatment. The international standards for medical records offer common models to organize information and ensure the exchange and interoperability between technical solutions. This paper analyzes the adoption of the main technical standards (ISO 13606 and HL7) in the Hcdsns project, developed by the Spanish Ministerio de Sanidad, Servicios Sociales e Igualdad. [ABSTRACT FROM AUTHOR]

En el presente número de MORFOLIA, y en el próximo, el Grupo de Anatomía Clínica y Quirúrgica VITRUVIO, presenta una extensa revisión de los más importantes aspectos del examen neurológico, dirigido a los estudiantes de las carreras de las ciencias de la salud, con la que se espera contribuir a superar, al menos en parte, con la "neurofobia", tendencia muy extendida entre los médicos y los estudiantes de medicina y de las demás áreas de las ciencias de la salud. [ABSTRACT FROM AUTHOR]

Background: Existing clinical guidelines do not offer an efficient alternative for the collection of data on relevant clinical traits during history and physical of the patient with chronic urticaria. Objective: Our aim was to provide a clinical data checklist together with its guide to allow for thorough information to be obtained and for a physical exam that identifies the main features and triggering factors of the disease to be carried out. Methods: A search was conducted for relevant literature on chronic urticaria in Medline, the Cochrane library and PubMed. Results: We developed an easy-to-use clinical data checklist with its corresponding clinical guide, comprised by 42 items based on two components: essential clues for history taking and chronic urticaria diagnosis (typical symptoms according to subgroups, etiology and laboratory results). Some components are the time of disease onset, wheals' duration, shape, size, color and distribution, associated angioedema, atopy, triggering factors and others. Conclusions: The clinical data checklist and its guide constitute a tool to focus, guide and save time in medical consultation, with the main purpose to aid physicians in providing better diagnosis and management of the disease. [ABSTRACT FROM AUTHOR]

Objective. To assess the compliance of the diagnosis and reporting from the Chikungunya cases in Ocaña, Colombia. Methods. Descriptive and retrospective study. 137 medical records of Chikungunya were reviewed, as well as their notification records from the epidemiologic vigilance system "SIVIGILA", between September 2014 and June 2015. Results. The number of Chikungunya cases reported so far is low compared with other regions in the country. The quality of the diagnosis of the Chikungunya virus in Ocaña is deficient in terms of the compliance from the quality markers established for the diagnostic process as well as for the event reporting. [ABSTRACT FROM AUTHOR]

Background: The increase of events adverse incidence as a result of preventable clinical practice errors calls the attention to the World Health Organization due to the enormous impact that these have in patients' health. Therefore, it is mandatory to establish the measures that guarantee the patient safety on the part of educational institutions that provide health services. Purpose: To identify, typify, and determine the frequency of adverse events detected in the dental records of patients that attended the Postgraduate program of Periodontics at the Pontifical University during the period of 2011 and 2012. Methods: In order to identify, typify and determine the frequency of the adverse events in Periodontics 929 dental records were analyzed. About 3.886 periodontal procedures were evaluated during 2011 and 2012. Results: The adverse events in periodontics found were 15 from 929 dental records analyzed. Within which preventable non clinic adverse events were observed in 9,43 % and preventable clinic adverse events were in 16,9 %, however, it was detected that from 1.738 surgical procedures only 406 cases had follow-up. Conclusion: The frequency observed of preventable adverse events in Periodontics indicates a low rate report in the dental records. Consequently, it also indicates that there is underreport of the follow-up information during postoperative controls, being important to create mechanisms of report and follow-up. [ABSTRACT FROM AUTHOR]

Background: Child abuse was first described in 1868 by pathologist Ambrosio Tardieu, but it was until the last century when the role of the dentist became relevant to early diagnose this syndrome. Several studies have shown that close to 50% of head and face trauma is caused by physical abuse of which lips are the most commonly injured site (54%), followed by oral mucosa, teeth, gums, and tongue. Complications of certain oral pathologies may be related to abuse for negligence. Bite marks have been associated to sexual abuse combined with oral lesions that appear as a result of sexually transmitted diseases. Parafunctional habits such as dental clenching (bruxism) have been linked to psychological abuse. Purpose: An extensive and detailed literature review of the clinical characteristics and proper handling when providing dental treatment to a child, who is presumably being abused, was carried out. The aim is for a dentist to early detect, document, consult with other professionals, and report cases of child abuse to authorities. [ABSTRACT FROM AUTHOR]

In this paper we'll address the issue of medical record in mental health. We structure this paper in four sections. First, we define what is the medical record, which is their content, and how it has to be structured. Second, we expose some deontological principles, ethical principles and ethical virtues to guide the development of the medical record and information management. Third, we analyze the question of who owns the medical record and who can access the information. Finally, we expose some empirical data about the opinion of both patients and professionals about the medical record. [ABSTRACT FROM AUTHOR]

Background: Clinical errors in health care can complicate even more a patient's health. In health care systems such as the Colombian it is compulsory to report and follow up such adverse events. Purpose: Describe the frequency and nature of adverse events identified in the clinical records of patients who attended the Endodontics Postdoctoral Clinics of the Pontificia Universidad Javeriana in Bogotá Colombia (2007-2008) and to describe the follow-up reported cases from the first period of 2007. Methods: In this descriptive study, the follow-up chart, radiographic records, and registry in the system (adverse event identification and follow-up model) of 464 clinical records were analyzed to identify adverse events associated with endodontic therapy. Those events could have happened during root canal opening, clean-up/shaping, filling, and post-treatment. Results: There were 306 adverse events related to endodontic treatment (74.4%). 81.3% were preventable events during canal opening (4.1%), clean-up/shaping (36.1%), and filling (60%). Crown perforations, root canal transportation, and overfilling were the most frequent events in the procedures mentioned before. On the other side, there were symptoms reported in 26.3% of the 2007 first-term follow-up cases studied. Conclusion: Since adverse events in endodontics identified in this study were very frequent, it is important to create mechanisms to determine causes and develop strategies to reduce them. [ABSTRACT FROM AUTHOR]

Introduction: The acronym, need to "linguistic economy" growing in the notes to physician practices, has become a key vocabulary and their indiscriminate use, involves risks of unintelligibility, being element in separation or misunderstanding communication. General objective: To determine the frequency of use of abbreviations in records of Pediatría General and Infectología Pediátrica from Hospital Universitario del Valle "Evaristo Garcia" (HUV) in Cali, Colombia. Specific objective: To reflect on the dangers of separation and misunderstanding in communication between health professionals and the doctor-patient interaction. Methodology: Abbreviations were revised from records of 200 children who were hospitalized in the HUV in Cali, Colombia, used by undergraduate medical students and postgraduate pediatrics and pediatricians and pediatric subspecialists to Universidad del Valle and the Hospital Universitario del Valle in Cali, Colombia. Results: There were 293 abbreviations and were written in 5759 opportunities, with an average of 28.79 times history (range 5-56), the most frequent was HR (heart rate = 210). Were most used by graduate students in pediatrics (31.3%). There was no meaning to 12 abbreviations (RHA, EE, RSPS, SSD, PP65, AH, D, IRA, CPI, ITS, MEO, CSPSVS) and 21 had more than two interpretations, being the SS abbreviation of more interpretations: weeks, social security, second and saline solution. Conclusions: Health professionals from HUV in Cali, Colombia, commonly used abbreviations, being some unintelligible and others with different meanings, what are dangers of separation and misunderstanding of communication between health professionals and health in children. [ABSTRACT FROM AUTHOR]

There is often a question of which is the correct way to write in the medical records, the name of people, who have not reached adulthood. We propose several alternatives that allow, within the regulatory framework, solve in a simple way this requirement for information on health. [ABSTRACT FROM AUTHOR]

A descriptive and cross-sectional study, aimed at evaluating the quality of the Comprehensive General Stomatology in the department of this specialty from "Ramón López Peña" University Polyclinic in Santiago de Cuba was carried out from November, 2008 to March, 2009, by means of the methodology proposed in the document for this aim. The universe was constituted by 20 general stomatologists and specialists in Comprehensive General Stomatology. The quality of the medical record was evaluated by means of criteria, indicators and standards used to evaluate the professional performance, which was inadequate. [ABSTRACT FROM AUTHOR]

The dysmorphology studies patterns of human development and structural defects, including malformations, disruptions, and deformity, among others. The personal and family medical history, give an insight into how they manifest and pass genetic traits. The genetic history, so other people other, prognosis and interventions to informmore appropriate or accurate. This article is an overview of the factors to be taken into account within the Clinical Genetics History. [ABSTRACT FROM AUTHOR]

The dysmorphology studies patterns of human development and structural defects, including malformations, disruptions, and deformity, among others. The personal and family medical history, give an insight into how they manifest and pass genetic traits. The genetic history, so other people other, prognosis and interventions to inform more appropriate or accurate. This article is an overview of the factors to be taken into account within the Clinical Genetics History. [ABSTRACT FROM AUTHOR]

A mental health information system, must meet the following minimum requirements if it is to be considered of good quality. The system must be patient centred, and the information must be longitudinal, accumulated, exhaustive and complete. This requires a unique universal identification code for each patient. The data recorded must comply with the guarantees of confidentiality and the minimum quality criteria to enable the drawing up of results that are useful for the scientific community, including clinicians, managers and researchers. For these information systems to be efficient, it is necessary for the clinicians to be involved in their development and to receive training for their correct use. Finally, these systems should receive institutional support and be considered a priority within the mental health care system. [ABSTRACT FROM AUTHOR]

Using the archival admissions records and the case history of a patient at a British asylum in the 1870s, the author compares two genres. The first of these is two medical certificates written and signed by two physicians attesting that the patient was of unsound mind and needed to be confined and treated. The second genre is the patient's oral testimony to Parliament's Select Committee on Lunacy Laws (1877), a narrative he delivered the year following his release from the asylum. Both genres are legal texts; however, it is the patient's narrative of personal experience, as transcribed in the committee report, that allows the reader a glimpse of the misery imposed by confinement in a "lunatic" asylum. The two medical certificates have considerably more illocutionary force, however; as speech acts they most often resulted in confinement until the patient was determined to have recovered, was transferred to another asylum, or died. [ABSTRACT FROM AUTHOR]

This paper studies the origin and evolution of three health archives at the Hospital de León that forms part of the Public Health Service of the region of Castilla and León (Spain). The principle of provenance is essential to decide upon the organisation of medical histories archives and all the documents included in them. The study assesses the management of the above mentioned health archives in order to highlight the importance of appropriate cataloguing, shelving and storage of medical records for an efficient day–to–day running of hospitals. The results will be useful in estimating the approximate cost of a proper archives management when taking into account factors such as patients staying longer than expected in hospital or the need to repeat medical tests. [ABSTRACT FROM AUTHOR]

Medical record is a document with particular characteristics that requires a different documental management, has different uses and users that use it with different interest, to preserve its usefulness and in order to comply the legal normativity from each country it is necessary to change the traditional way it have been build (through manuscript files addition) and apply new technologies of the information and communication (TIC). This article presents the main different advantages and disadvantages of the Computarized Medical Records (CMR) compared with the traditional paper MR, according to it's different uses and users as well as the required conditions to make each one of it an efficient document. Colombian and Spain cases were analyzed, comparing normative conditions and technological development, with the proposal of obtaining a comparative parameter that allow us to determine future trends in the integration of the models. [ABSTRACT FROM AUTHOR]

Introducción: Osakidetza atiende en el País Vasco a una población de 2.188.985 personas. La necesidad de establecer un plan individualizado de paciente que garantice una continuidad asistencial y su participación, es un reto imprescindible para la atención integrada de cualquier organización. Un innovador sistema de información, que incorpore una visión ágil, sencilla e integrada es fundamental para ayudar en la toma de decisiones. Teoría/métodos: Osakidetza ha desarrollado Osabide-Global (Historia Clínica Electrónica unificada), utilizando metodología scrum fundamentada en el feedback con los profesionales (Primaria-Hospitalaria-Servicios Sociales), facilitando la transmisión de la información generada en cada atención sanitaria y la interacción entre profesionales y con el paciente a través de carpeta de salud. La consulta de la gran cantidad de información generada en Primaria-Hospitalaria-Residencias (300 centros sociosanitarios) sin perder la visión del paciente como centro de atención ha precisado un análisis metodológico sobre la forma óptima de su presentación para que se pueda ver de una forma clara, sencilla e integradora, aportando coherencia a todo el proceso de atención del paciente. Resultados: Implantación en todo Osakidetza de un timeline integrado en Osabide-Global centrado en el paciente, con toda la información asistencial presencial y no presencial que se genera durante la atención sanitaria tanto en centros sanitarios como en residenciassociosanitarias. En Osabide-Global, al e-book del paciente (evolutivos) se ha incorporado este timeline que aporta un salto cualitativo en la gestión de la información facilitando la interpretación clínica y la toma de decisiones por diferentes profesionales para generar un plan individualizado del paciente. El timeline se genera y actualiza automáticamente con cada atención, representando gráficamente todas las intervenciones (fecha inicio-fin) en una línea del tiempo interactiva. Discusión: Generalmente visualizamos la historia clínica por procesos registrados aislados. Una atención integrada debe fundamentarse en el análisis global de todos los procesos activos que permita establecer el mejor plan terapéutico al paciente. Información del paciente visualizada conjuntamente en Timeline: Procesos-diagnósticos Actividad asistencial: Ingresos, urgencias, hospitalización a domicilio Situación laboral Receta electrónica Solicitud de consultas, radiología, pruebas complementarias. Evolutivos Registros de formularios (escalas, registros patologías) El Timeline interactivo permite acceder a los datos directamente en el sistema de información origen. Lecciones aprendidas: Aprender de experiencias previas: Osakidetza con la receta electrónica generó un timeline que permite ver todos los medicamentos prescritos y su recogida en las farmacias, con información actualizada de la adherencia. La excelente aceptación de los profesionales ha sido clave para el nuevo timeline con información integrada de diferentes sistemas de información. Participación de los profesionales en el diseño es clave incorporando la experiencia de usuario con un diseño sencillo e interactivo centrado en el paciente. Limitaciones: El timeline supone incorporar una integración completa de los sistemas de información de la historia clínica. Sugerencias para el futuro: Debemos potenciar el desarrollo de representaciones interactivas de la información contenida en la historia clínica fundamentada en diseños atractivos para los profesionales y pacientes que faciliten el acceso a la información y permitan interacciones y sirvan de apoyo en la toma de decisiones y la generación de planes individualizados. [ABSTRACT FROM AUTHOR]