An approach to the medical record: a guide

Abstract

Science is content expressed as knowledge, and art are practical habits and skills of the medical profession. Medical diagnosis that beginners perceive as intuitive deductions, comparable to a detective’s task, are just the result of a reasoning process that mixes both, learning and experience. The medical record is the core document and a key weapon for the diagnosis of a disease. It is a compilation of valuable data for doctors and nurses that allows the establishment of diagnostic hypothesis and is also a source for analysis by other physicians. The authors dedicate this manual primarily to students as a practical guide for making a medical record.