The electronic file has replaced the traditional paper file as the main means of information storage in many organizations.
In this case, the clinical file contains a group of information and personal data of a patient, which is integrated into the institutions for medical care and supports all the documents that are part of the patient’s medical history.
There are many advantages to using clinical records, such as:
Agile procedures
Records with legal validity
Easy to access and share
advanced security
The clinical file could have a national database of patients, where a file can be sent from one institution to another, where several doctors can consult it remotely.
It is important that clinical records contain the following information:
- Medical history: This contains family history, pre-existing health problems, reason for visit, allergies, and current health status.
- Results of laboratories and studies carried out in the institution: Any laboratory examination or study that has been carried out in the health center will be kept in the clinical file to establish a history.
- Admission form: When a patient enters a health center due to an emergency, the date of admission, causes and personal data of the patient are recorded.
- Record of medical indications or evaluation: This document must specify the date on which it was carried out, the time and the patient’s data.
Through the chain of blocks, it is guaranteed that a medical prescription or a clinical file is not altered. The information sent through a chain of blocks, has:
Information about medications, treatment, tests, etc. Be available to everyone.
Encrypted and confidential information, such as the patient’s personal data, that is only visible to the doctor and the patient.
A seal that authenticates its validity through an official digital signature, which authenticates the accredited doctor.
If a document with all these characteristics is created, there is already a block of information and when you distribute it through a trusted network that will maintain a digital copy that will guarantee that this document can be consulted at any time, then a chain is created. and security will be guaranteed.
The clinical record becomes an important tool for the doctor because it contains all the information necessary to treat a patient in the most efficient way possible with respect to time and resources.
https://blog.prescrypto.com/tecnologia-medica/cadena-de-bloques-en-la-salud/
