MEDICAL RECORDS AND OTHER MEDICOLEGAL DOCUMENTS

Abstract

The purpose of this article, give out raises, from a very general point of view, the basic document of the medical-care practice, in which to find statistic all y responsible for performing working a health center. We discussed clinical medical records and other legal documents, in the medical-document type, are perhaps the most important of all documents that are handled in the system of public and private health.

The medico legal documents are all gmedical actions(a) in their professional relations with the authorities, agencies, institutions, patients and others.This group includes those documents that do not acquire evidence in the very act of incurred, butlater, under different causes that befall them. The main types of reports are: a) Certificates, b) Consultation, c) The opinion d) Health d) (ClinicalHistory) e) Prescription.

The second group includes documents created with the sole purpose of serving as evidence impossible litigation. The main ones are: the death certificate of forensic and legal medical expert opinion. Medical auditis an analytical, evaluative, technical procedure of both preventive and corrective, in order to give an ,report or independent certification regarding the medical procedure and the management of quality health services. Medical audit will be carried out only by medical professionals dulyac credited Medical Auditors by the Ministry of Health and Sports in coordination with the Medical College of Bolivia, while the legal medical expert, will be ordered through tax demand and warrant; expertise serves to discover or evaluate a piece of evidence. There for e you should not use the term Medical Audit, as a synonym for Forensic Evaluationals os hould be not ed that the medical forensic auditit self do es not exist.