Informe sobre la construcción del sistema informático de ghistorias clinicas del Instituto Psiquiátrico Sagrado Corazón de Jesús

Abstract

The clinical history is a compendium of information written in the so-called evolution sheets in which the information obtained or collected by a psychiatrist about his patient is captured. The clinical history itself is very important in the area of ​​psychiatry, which accounts for everything that happens to patients suffering from mental illness, whether ambulatory, hospitalized for recovery or residents in the hospital. In this way with the medical history we can know what has happened to the patient, and determine what means to use to achieve their recovery. The medical history is constructed by recording the information from the psychiatric interview. The psychiatric interview is the main weapon of the psychiatric task, to arrive at the understanding and knowledge of the person who needs intervention of the psychiatrist. The success of the interview is achieved with a good mutual understanding between doctor and patient. The main function of the interviewer is to listen and understand the patient, in the best possible way, in order to help him. The establishment of a good doctor-patient relationship is the first step and is indispensable to achieve treatment efficiency, either only therapeutic (psychotherapy), or if the use of drugs is decided, and this is only achieved by good contact with The patient, who begins in the first meeting between patient and doctor and continues in successive reviews, in which the psychiatric interview is used as the main test. The more knowledge they have of mental illness, the more relevant data can be obtained for diagnosis and therapy. In the psychiatric interview, not only must be taken care of what the patient reports, that is the verbal part, also must take into account a detailed observation of all non-verbal transmission such as movements, dress, gestures of the patient, expressions Emotional and how the patient reacts to certain issues "