Theoretical considerations on clinical history from its educational, value in Internal Medicine

Abstract

Introduction: Clinical histories or medical records are considered a basic medical-legal document in all stages of medical care, which should be appreciated as a methodological guide for the comprehensive identification of each person's health problems. Objective: To establish theoretical considerations about clinical history from its educational value. Methodology and methods: Observational qualitative research based on normative and operational documents established for the adequate preparation of the clinical history.  A documentary analysis was carried out in this regard. Results: The clinical history is educational because it is not only intended to solve the problems of a patient, but also scientifically helps the professional who handles it to be properly oriented to be able to solve them since, at the bottom of all activity Some form of prediction underlies the guiding principle, which is not a puzzle, but a scientific conjecture because it presupposes a journey from a current state to a desired state. Conclusions: The relevance of the considerations that are presented contribute to enrich the theoretical-methodological foundations in the aforementioned object of investigation, in the dynamic doctor-patient relationship, with an impact on the professional training corresponding to different university careers in the medical sciences, in special to Internal Medicine.