{"id":378,"date":"2017-05-09T23:46:45","date_gmt":"2017-05-10T04:46:45","guid":{"rendered":"https:\/\/agendapro.com\/blog\/?p=378"},"modified":"2024-06-19T17:06:35","modified_gmt":"2024-06-19T23:06:35","slug":"como-configurar-una-historia-clinica-en-colombia","status":"publish","type":"post","link":"https:\/\/agendapro.com\/blog\/como-configurar-una-historia-clinica-en-colombia\/","title":{"rendered":"\u200bC\u00f3mo configurar una historia cl\u00ednica en Colombia"},"content":{"rendered":"<p>En la historia cl\u00ednica se registran cronol\u00f3gicamente las condiciones de salud de un paciente, las intervenciones m\u00e9dicas y dem\u00e1s procedimientos ejecutados durante su atenci\u00f3n, tratamiento y rehabilitaci\u00f3n. Es determinante como sustento legal, t\u00e9cnico, cient\u00edfico y\/o administrativo de las acciones realizadas. Por lo tanto, saber configurarla es imprescindible. Aprende c\u00f3mo hacerlo de acuerdo al <a href=\"https:\/\/www.minsalud.gov.co\/Normatividad_Nuevo\/RESOLUCI%C3%93N%201995%20DE%201999.pdf\" target=\"_blank\" rel=\"noopener\">marco legal y t\u00e9cnico para el diligenciamiento de historiales cl\u00ednicos<\/a>.<\/p>\n<p><!--more--><\/p>\n<h2>Directrices para la apertura de una historia cl\u00ednica en Colombia<\/h2>\n<p>La identificaci\u00f3n del historial m\u00e9dico debe corresponder a los siguientes lineamientos:<\/p>\n<ul>\n<li>Mayores de edad: n\u00famero de c\u00e9dula de ciudadan\u00eda.<\/li>\n<li>Menores de entre 7 y 18 a\u00f1os: n\u00famero de la tarjeta de identidad.<\/li>\n<li>Menores de 7 a\u00f1os: n\u00famero del registro civil.<\/li>\n<li>Extranjeros: c\u00e9dula de extranjer\u00eda o pasaporte.<\/li>\n<\/ul>\n<p>Si los menores de edad no tienen identificaci\u00f3n tienes que ejecutar la apertura con el n\u00famero de c\u00e9dula de alguno de los padres, seguido del n\u00famero que indique el puesto del menor en el grupo familiar.<\/p>\n<h2>\u00bfQu\u00e9 debe anotarse en una historia cl\u00ednica en Colombia?<\/h2>\n<p>A la hora de configurar historia cl\u00ednica debes apuntar el estado de salud. Por ellas se entienden los datos relacionados con las condiciones som\u00e1ticas, ps\u00edquicas, sociales, y medioambientales que inciden en la salud del paciente.<\/p>\n<p>De otra parte, debes <a href=\"https:\/\/agendapro.com\/co\/historia-clinica\" target=\"_blank\" rel=\"noopener\">anotar en la ficha cl\u00ednica<\/a> todos los aspectos cient\u00edficos, t\u00e9cnicos y administrativos que tienen que ver con la atenci\u00f3n, diagn\u00f3stico, tratamiento y rehabilitaci\u00f3n de la enfermedad.<\/p>\n<h2>\u00bfC\u00f3mo se diligencia una ficha cl\u00ednica en Colombia?<\/h2>\n<p>Escribe de forma clara, legible y sin enmendaduras, tachones ni espacios en blanco. Identifica cada anotaci\u00f3n con la fecha y hora en la que la realizaste, acompa\u00f1ada de tu nombre completo y firma. Igualmente es obligatorio que registres tus observaciones, conceptos y decisiones, as\u00ed como las advertencias que hagas con respecto al riesgo previsto.<\/p>\n<p>Finalmente, para configurar historia cl\u00ednica es necesario que incluyas los soportes de todo procedimiento, como ex\u00e1menes paracl\u00ednicos, im\u00e1genes diagn\u00f3sticas y dem\u00e1s por el estilo.<\/p>\n<p>El documento puede archivarse en papel y en <a href=\"\/blog\/como-un-crm-ayuda-a-proteger-la-informacion-de-tu-negocio\">medios digitales que almacenen el historial de los pacientes<\/a>, siempre y cuando los equipos de almacenamiento sean seguros e imposibiliten las modificaciones luego de configurar historia cl\u00ednica. De hecho, nosotros siempre recomendamos usar un <a href=\"https:\/\/agendapro.com\/co\/clinica\/software-para-clinica\" rel=\"noopener\">sofware para cl\u00ednicas con ficha m\u00e9dica digital<\/a> como AgendaPro, para almacenar toda la informaci\u00f3n de manera segura y accesible.<\/p>\n<p><strong>Tambi\u00e9n te podr\u00eda interesar:<\/strong><\/p>\n<ol>\n<li style=\"text-align: left; font-weight: normal;\"><a href=\"\/blog\/por-que-usar-un-software-de-historia-clinica\">Por qu\u00e9 usar un software de historia cl\u00ednica<\/a><\/li>\n<li style=\"text-align: left; font-weight: normal;\"><a href=\"\/blog\/como-realizar-una-historia-clinica\">C\u00f3mo realizar una historia cl\u00ednica<\/a><\/li>\n<li style=\"text-align: left; font-weight: normal;\"><a href=\"\/blog\/c\u00f3mo-hacer-una-historia-clinica-en-mexico\">C\u00f3mo realizar una historia cl\u00ednica en M\u00e9xico<\/a><\/li>\n<li style=\"text-align: left; font-weight: normal;\"><a href=\"\/blog\/como-hacer-una-historia-clinica-psicologica\">C\u00f3mo hacer una historia cl\u00ednica psicol\u00f3gica<\/a><\/li>\n<li style=\"text-align: left; font-weight: normal;\"><a href=\"\/blog\/historia-medica-pediatrica-todo-lo-que-necesitas-saber\">C\u00f3mo hacer una historia m\u00e9dica pedi\u00e1trica\u00a0<\/a><\/li>\n<li style=\"text-align: left; font-weight: normal;\"><a href=\"https:\/\/agendapro.com\/co\/ginecologos\/software-de-ginecologia\" target=\"_blank\" rel=\"noopener\">Software para cl\u00ednicas ginecol\u00f3gicas<\/a><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>En la historia cl\u00ednica se registran cronol\u00f3gicamente las condiciones de salud de un paciente, las intervenciones m\u00e9dicas y dem\u00e1s procedimientos&#8230;<\/p>\n","protected":false},"author":1,"featured_media":379,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[34],"tags":[],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v22.8 (Yoast SEO v22.8) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>\u200bC\u00f3mo configurar una historia cl\u00ednica en Colombia<\/title>\n<meta name=\"description\" content=\"\u00bfC\u00f3mo configurar una historia cl\u00ednica en Colombia?\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/agendapro.com\/blog\/como-configurar-una-historia-clinica-en-colombia\/\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"\u200bC\u00f3mo 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