Abstract
Background
The medical record is an ethical legal instrument of paramount importance for patients, the institution, the health team, teaching, and research.
Objective
To present the historical path of the medical record in the health record and to point out current tensions linked to this procedure.
Method
The National Humanization Policy was adopted as a theoretical reference for the presentation of a reflexive analysis on the subject, which was based on data obtained from bibliographical research and a documentary study involving guidelines from the professional classes and documents of the Health Ministry.
Results
The historical development of the medical record is related to the development of medicine and to the evolution of the hospital institution and the current requirement of the quality of medical records is driven by aspects of institutional management.
Conclusion
The main challenges involved in carrying out the procedure of registers are linked to the process of initial and continuing education and the need to elucidate more manageable ways of documenting clinical practice, allowing quality records, guaranteeing the communication of evidence in the documentation, and promoting the practice of the extended clinic.
Keywords:
medical records; hospital; documentation; humanization of assistance
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