<?xml version="1.0" encoding="ISO-8859-1"?><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<front>
<journal-meta>
<journal-id>0120-386X</journal-id>
<journal-title><![CDATA[Revista Facultad Nacional de Salud Pública]]></journal-title>
<abbrev-journal-title><![CDATA[Rev. Fac. Nac. Salud Pública]]></abbrev-journal-title>
<issn>0120-386X</issn>
<publisher>
<publisher-name><![CDATA[Universidad de Antioquia]]></publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id>S0120-386X2023000200004</article-id>
<article-id pub-id-type="doi">10.17533/udea.rfnsp.e350725</article-id>
<title-group>
<article-title xml:lang="es"><![CDATA[Calidad del registro de la historia clínica: autocrítica desde los médicos internistas]]></article-title>
<article-title xml:lang="en"><![CDATA[Quality of medical record documentation: general internists self-criticism]]></article-title>
<article-title xml:lang="pt"><![CDATA[Qualidade do registro da história clínica: autocrítica dos internistas]]></article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname><![CDATA[López-Cano]]></surname>
<given-names><![CDATA[Lina María]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Yepes-Delgado]]></surname>
<given-names><![CDATA[Carlos Enrique]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
</contrib-group>
<aff id="Af1">
<institution><![CDATA[,Universidad de Antioquia  ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Colombia</country>
</aff>
<aff id="Af2">
<institution><![CDATA[,Universidad de Antioquia  ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Colombia</country>
</aff>
<pub-date pub-type="pub">
<day>00</day>
<month>08</month>
<year>2023</year>
</pub-date>
<pub-date pub-type="epub">
<day>00</day>
<month>08</month>
<year>2023</year>
</pub-date>
<volume>41</volume>
<numero>2</numero>
<copyright-statement/>
<copyright-year/>
<self-uri xlink:href="http://www.scielo.org.co/scielo.php?script=sci_arttext&amp;pid=S0120-386X2023000200004&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://www.scielo.org.co/scielo.php?script=sci_abstract&amp;pid=S0120-386X2023000200004&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://www.scielo.org.co/scielo.php?script=sci_pdf&amp;pid=S0120-386X2023000200004&amp;lng=en&amp;nrm=iso"></self-uri><abstract abstract-type="short" xml:lang="es"><p><![CDATA[Resumen  Objetivo:  Describir la reflexión autocrítica que médicos especialistas en medicina interna hacen de la calidad del registro de la información en la historia clínica electrónica, en el Hospital Pablo Tobón Uribe.  Metodología:  Estudio cualitativo que aplicó técnicas de la teoría fundamentada, con entrevistas semiestructuradas en profundidad a quince médicos internistas de un hospital de alta complejidad en Medellín, Colombia. El análisis partió de una conceptualización con codificación abierta y, luego, se hizo la agrupación de códigos en categorías descriptivas. Se identificaron propiedades y dimensiones que fueron relacionadas mediante la codificación axial con la matriz del paradigma de la teoría fundamentada, que permitió la emergencia de una categoría más abstracta.  Resultados:  Los entrevistados manifestaron que la historia clínica guarda información fundamental e invaluable, que contribuye al mejoramiento de la sa¬lud de los pacientes. Relacionaron la calidad del diligenciamiento de la historia clínica con un contexto regulatorio nacional, el cual tiene exigencias administrativas y financieras que ejercen presión de requerimientos externos a la clínica sobre su diligenciamiento. Se reconoce la influencia de la cultura digital y del inmediatismo, debilidades en la formación del diligenciamiento de la historia clínica tanto en pregrado y posgrado. Lo anterior distancia al médico del paciente, genera desmotivación en el ejercicio de su profesión y facilita cometer errores.  Conclusiones:  Existe una contradicción entre el &#8220;deber ser&#8221; del diligenciamiento con calidad de la historia clínica y lo que sucede en la práctica, pues su intencionalidad original de ser una herramienta al servicio de la asistencia clínica se desvirtúa, al privilegiar el haberse convertido en un instrumento que responde a otros factores externos del sistema de salud del país.]]></p></abstract>
<abstract abstract-type="short" xml:lang="en"><p><![CDATA[Abstract  Objective:  to describe the self-critical reflection that internal medicine specialists make on the quality of the information recorded in the electronic medical record in a high complexity hospital.  Methodology:  qualitative study that applied Grounded Theory techniques, with semi-structured in-depth interviews to fifteen internists of the Pablo Tobón Uribe Hospital in Colombia. The analysis was based on a conceptualization with open coding and then grouping of codes into descriptive categories. Properties and dimensions were identified and related through axial coding with the matrix of the Grounded Theory paradigm, which allowed the emergence of a more abstract category.  Results:  the interviewees informed the medical records keeps invaluable and fundamental information which contributes to the improvement of patient &#769;s health. They related the quality of medical records fill out with a national regulatory context, which has administrative and financial challenges that demands external pressure over the completion requirements in the medical assistance. The influence of digital culture and immediacy and insufficiencies skills in undergraduate and postgraduate medical training for a comprehensive fill out medical records, are recognized. The above distances the physician from the patient, generates demotivation in the practice of his profession and makes it easier to make mistakes.  Conclusions:  there is a contradiction between the &#8220;should be&#8221; of the quality of the medical records and what happens in practice, since its original intention of being a tool at the service of clinical care is distorted, as it has become a tool that responds to other external factors to the National health system.]]></p></abstract>
<abstract abstract-type="short" xml:lang="pt"><p><![CDATA[Resumo  Objetivo:  Descrever a reflexão autocrítica que os médicos especialistas em medicina interna fazem sobre a qualidade da informação registrada no prontuário eletrônico do Hospital Pablo Tobón Uribe.  Metodologia:  Estudo qualitativo que aplicou técnicas de teoria fundamentada, com entrevistas semiestruturadas em profundidade com quinze internos de um hospital de alta complexidade em Medellín, Colômbia. A análise partiu de uma conceituação com codificação aberta e, em seguida, foi feito o agrupamento dos códigos em categorias descritivas. Foram identificadas propriedades e dimensões que se relacionaram por meio da codificação axial com a matriz do paradigma da teoria fundamentada, o que permitiu o surgimento de uma categoria mais abstrata.  Resultados:  Os entrevistados relacionaram a qualidade do preenchimento da história clínica com um contexto regulatório que impõe exigências administrativas e financeiras que exercem pressão de exigências externas à clínica no seu preenchimento. Reconhece-se a influência da cultura digital e do imediatismo, as insuficiências na formação médica graduada e pós-graduada e as limitações dos médicos nas habilidades de comunicação. Isso distancia o médico do paciente, gera desmotivação no exercício de sua profissão e facilita erros.  Conclusões:  Existe uma contradição entre o "deveria ser" de preencher a anamnese com qualidade e o que ocorre na prática, pois sua intenção original de ser uma ferramenta a serviço do atendimento clínico é desvirtuada, ao privilegiar ter se tornado um instrumento que responde a outros fatores externos ao ato médico e às exigências administrativas do sistema de saúde.]]></p></abstract>
<kwd-group>
<kwd lng="es"><![CDATA[calidad de la atención de salud]]></kwd>
<kwd lng="es"><![CDATA[historia clínica]]></kwd>
<kwd lng="es"><![CDATA[medicina interna]]></kwd>
<kwd lng="es"><![CDATA[registros electrónicos de salud]]></kwd>
<kwd lng="es"><![CDATA[sistemas de información en hospital]]></kwd>
<kwd lng="es"><![CDATA[teoría fundamentada]]></kwd>
<kwd lng="en"><![CDATA[Quality of Health Care]]></kwd>
<kwd lng="en"><![CDATA[Medical Records]]></kwd>
<kwd lng="en"><![CDATA[Hospital Information Systems]]></kwd>
<kwd lng="en"><![CDATA[Electronic Health Records]]></kwd>
<kwd lng="pt"><![CDATA[qualidade dos cuidados de saúde]]></kwd>
<kwd lng="pt"><![CDATA[história clínica]]></kwd>
<kwd lng="pt"><![CDATA[medicina interna]]></kwd>
<kwd lng="pt"><![CDATA[registros eletrônicos de saúde]]></kwd>
<kwd lng="pt"><![CDATA[sistemas de informação hospitalar]]></kwd>
<kwd lng="pt"><![CDATA[teoria fundamentada]]></kwd>
</kwd-group>
</article-meta>
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