The medical history: A vision from bioethics

Abstract

The Medical History (MH) is the essential document of learning and clinical practice. Recognized as a fundamental element in the doctor-patient relationship, it is based on semiology, the clinical method; bioethical and legal parameters for its elaboration, quality, and administrative management. Its periodic audit guarantees adequate patient care and health activity. The collection of information must observe the principle of quality, with aspects of purpose, relevance, and truthfulness, as a process of a moral medical act that integrates the Lex Artis of the doctor. The challenges of data security in its digital version, from technology and law, should not be a reason for resistance, since it is an optimal way out in achieving quality of health service. An objective regulatory standard is required in the law of the practice of medicine and other health professions. Bioethical deliberation is the best way for this process.