ISSN: 2642-6250
Authors: Turabian JL*
The most common form of narration or biography of the disease consists of the clinical history and the annotations of the clinicians. The increasing availability of data stored in electronic health records brings substantial opportunities for advancing patient care and population health. But still there is a challenge in electronic health record in general medicine. Electronic health records for general medicine should be based on the concepts of this specialty, and the use of the tool should promote the tendency to routinely use the basic elements of general medicine. In this way, the desirable characteristics of electronic health records in general medicine are: 1) Clinical usability; 2) That is not electronic health records a barrier to communication and doctor-patient relationship; 3) Narrative; 4) Relational; 5) Flexible; 6) Decentralized base, at least in part; 7) That electronic health records show the multiplicity of chronological times; 8) Multiplicity of techniques; 9) Oriented to the context; and 10) Clinical decision support. This implies technological characteristics such as: a) free text; b) allow visualization in graphic form of multiple patient connections; c) a patient image on a timeline, to which a collection of objects can be added on screen; d) presence of clinical notes, interviews, transcriptions of audio tapes, diaries personal, video recordings, etc; e) a visualization in grid or by biological, psychological and social planes, f) and finally, the possibility that the individual himself can cooperate in his history, which also maintains and controls in part.
Keywords: Family Physician; Family Practice; Communication; Education, Medical; Electronic Health Records; Medical Record; Physician-Patient Relations; Physician's Role; Family Medical History; Personal Health Records; History Taking Medical
