The importance of electronic medical records for medical expertise

• Autor(a) principal: Araújo, Yanne Pinheiro de
• Data de Publicação: 2020
• Outros Autores: Oliveira, Halley Ferraro, Carranza, Brenda Louise Prado, Lima, Marina Guimarães, Chaves, Renata Calhau Bezerra
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Scire Salutis
• Texto Completo: https://sustenere.inf.br/index.php/sciresalutis/article/view/CBPC2236-9600.2020.001.0004
• topic: Prontuário Eletrônico; Prova Pericial; Medicina Legal; Electronic Health Record; Expert proof; Legal Medicine

The organized and concise electronic health record (EHR) has several advantages, such as ease of storage, safety and reliability, with legal effects. The aim of this paper is to perform a literature review on the importance of electronic health record in expert examinations. Articles were searched in the Databases: Pubmed, Scielo, Bireme, books on Forensic Medicine and Applied Legislation. There were few publications relevant to the theme, with only 09 references; EHR is one of the most important documents in judicial matters and has been increasingly used by health professionals; EHR document storage on digital media gives you a higher level of security in your data. It is essential that the electronic health record is complete, because if it is incomplete, illegible or does not exist, the coroner will not be able to use this information to substantiate the expert report. Therefore, the Health Institutions have the duty to keep the medical record up to date and under their custody, ready at any time for consultation, or through a legal claim to be sent a true copy to the court provoked. Although the electronic medical record is one of the main documents for medical expertise, there were not many publications of scientific papers for further study of the subject. However, it was possible to realize that its digitalization brought greater ease of access, storage, and greater legal certainty for both the physician and the expert.