Aspectos técnicos, éticos e legais na elaboração do prontuário médico-veterinário

Abstract

The medical record is a document that compiles the entire clinical history of a patient, which is based on all medical procedures performed and must include all of the relevant documents of the case. It is seen that nowadays there are still many drawbecks in filling and preparing medical records and that in Veterinary Medicine the discussion of this topic is very scarce. This work presents how should be the correct structure of this document, what information it must contain and how the proper terms of free and informed consent could be elaborated. The importance of developing a standardized medical record is discussed, so the patient could be attended in any establishment, and his record would be available to the veterinarian. The use of the medical record and its relationship with the consumer protection code, elucidates how the medical record correctly filled could assist the professional in his routine, and also when he needs to perform his defense in the judicial sphere, as in the case of accusation of a veterinary medical error. The paper was written to keep the professionals informed about the importance of preparing and filling out the medical record, and also presents a proposal for a unified veterinary medical record.