{"id":27466,"date":"2024-05-20T07:19:14","date_gmt":"2024-05-20T07:19:14","guid":{"rendered":"https:\/\/www.techopedia.com\/es\/?post_type=definition&#038;p=27466"},"modified":"2024-05-20T08:20:42","modified_gmt":"2024-05-20T08:20:42","slug":"historia-clinica-electronica","status":"publish","type":"definition","link":"https:\/\/www.techopedia.com\/es\/definicion\/historia-clinica-electronica","title":{"rendered":"Historia cl\u00ednica electr\u00f3nica"},"content":{"rendered":"<h2><span id=\"que_significa_historia_clinica_electronica\">\u00bfQu\u00e9 significa historia cl\u00ednica electr\u00f3nica?<\/span><\/h2>\n<p>Una historia cl\u00ednica electr\u00f3nica (HCE) es una historia cl\u00ednica digital que se origina en un formato electr\u00f3nico o se convierte de papel o copia impresa a una versi\u00f3n en l\u00ednea.<strong> Un EMR incluye informaci\u00f3n sobre un paciente espec\u00edfico, incluyendo:<\/strong><\/p>\n<ul>\n<li>Informaci\u00f3n de contacto del paciente, incluidos los contactos de emergencia.<\/li>\n<li>Constantes vitales, como altura, peso, \u00edndice de masa corporal (IMC) y temperatura corporal.<\/li>\n<li>Citas anteriores y futuras con centros m\u00e9dicos.<\/li>\n<li>\u00d3rdenes del m\u00e9dico.<\/li>\n<li>Recetas m\u00e9dicas.<\/li>\n<li>Evoluci\u00f3n m\u00e9dica y notas quir\u00fargicas.<\/li>\n<li>Formularios de consentimiento para divulgar informaci\u00f3n.<\/li>\n<li>Alergias.<\/li>\n<li>Historial m\u00e9dico anterior.<\/li>\n<li>Informaci\u00f3n de facturaci\u00f3n, como el seguro.<\/li>\n<li>Res\u00famenes de alta y planes de tratamiento.<\/li>\n<\/ul>\n<p>Un REM tambi\u00e9n se conoce como historia cl\u00ednica electr\u00f3nica (HCE).<\/p>\n<h2><span id=\"definicion_de_historia_clinica_electronica\">Definici\u00f3n de historia cl\u00ednica electr\u00f3nica<\/span><\/h2>\n<p>La implantaci\u00f3n de la historia cl\u00ednica electr\u00f3nica es m\u00e1s que un avance tecnol\u00f3gico. Se origin\u00f3 con la Ley de Tecnolog\u00eda de la Informaci\u00f3n Sanitaria para la Salud Econ\u00f3mica y Cl\u00ednica (HITECH), <strong>promulgada por el Presidente Obama en 2009<\/strong>, y legislada como parte de la Ley de Recuperaci\u00f3n y Reinversi\u00f3n Estadounidense de 2009 (ARRA), o Ley de Est\u00edmulo, que asign\u00f3 36.500 millones de d\u00f3lares para que el sector sanitario convirtiera las historias cl\u00ednicas electr\u00f3nicas (HCE) del papel al formato electr\u00f3nico.<\/p>\n<p>Esto incluye fondos para contratar a proveedores y especialistas en HCE\/HCE y ofrecer incentivos a los proveedores de Medicare y Medicaid que avancen hacia la implantaci\u00f3n de HCE. A medida que se imponga la implantaci\u00f3n de la HCE, se pondr\u00e1n a disposici\u00f3n de los proveedores de HCE futuros incentivos. La fecha l\u00edmite para la conversi\u00f3n de datos m\u00e9dicos es 2015.<\/p>\n<p><strong>Las ventajas de la HCE son numerosas.<\/strong> Una raz\u00f3n clave es la noci\u00f3n de que las HCE pueden salvar vidas al reducir los errores humanos. Por ejemplo, si los m\u00e9dicos y enfermeros disponen de informaci\u00f3n m\u00e9dica electr\u00f3nica crucial al alcance de la mano, cabe esperar menos retrasos en los tratamientos de urgencia y los cuidados cr\u00edticos. Las HCE tambi\u00e9n resultan c\u00f3modas para los pacientes, al eliminar el repetitivo proceso de divulgar historiales m\u00e9dicos a nuevos cuidadores.<\/p>\n<p>Sin embargo, las leyes de confidencialidad deben estudiarse m\u00e1s a fondo, y la seguridad de la HCE puede tener que afinarse, especialmente en lo que se refiere a los registros de conducta y abuso de sustancias. Otro problema es la implantaci\u00f3n de la HCE en consultas m\u00e9dicas peque\u00f1as con poco o ning\u00fan apoyo inform\u00e1tico.<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\u00bfQu\u00e9 significa historia cl\u00ednica electr\u00f3nica? Una historia cl\u00ednica electr\u00f3nica (HCE) es una historia cl\u00ednica digital que se origina en un formato electr\u00f3nico o se convierte de papel o copia impresa a una versi\u00f3n en l\u00ednea. Un EMR incluye informaci\u00f3n sobre un paciente espec\u00edfico, incluyendo: Informaci\u00f3n de contacto del paciente, incluidos los contactos de emergencia. Constantes [&hellip;]<\/p>\n","protected":false},"author":7813,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","format":"standard","meta":{"_acf_changed":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"definitioncat":[31],"class_list":["post-27466","definition","type-definition","status-publish","format-standard","hentry","definitioncat-gestion-datos"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.2 (Yoast SEO v24.5) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Historia cl\u00ednica electr\u00f3nica: Caracter\u00edsticas y ventajas<\/title>\n<meta name=\"description\" content=\"Te damos a conocer lo que incluye y cu\u00e1les son las ventajas de una historia cl\u00ednica electr\u00f3nica en el sector m\u00e9dico.\" \/>\n<meta name=\"robots\" content=\"noindex, follow\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" 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