Resumen

CARVAJAL OVIEDO, Hugo Eduardo et al. Clinical records and other documents as evidence forensic medical practice. Arch.Boliv.Med. [online]. 2013, vol.20, n.88, pp. 60-73. ISSN 0004-0525.

The medico legal documents are all written using medical actions (a) in their professional relations with the authorities, agencies, institutions, patients and others. This group includes those documents that do not acquire evidence in the very act of incurred, but later, under different causes that befall them. The main types of reports are: a) Certificates, b) Consultation, c) The opinion d) Health Record (Clinical History) e) Prescription. The second group includes documents created with the sole purpose of serving as evidence in possible litigation. The main ones are: the death certifícate of forensic and legal medical expert opinion. Medical audit is an analytical, evaluative, technical procedure of both preventive and corrective, in orderto give an opinion, report or independent certification regarding the medical procedure and the management of quality health services. Medical audit will be carried out only by medical professionals duly accredited Medical Auditors by the Ministry of Health and Sports in coordination with the Medical College of Bolivia, while the legal medical expert, will be ordered through tax demand and warrant; expertise serves to discoveror evaluate a piece of evidence. Therefore you should not use the term Medical Audit, as a synonym for Forensic Evaluation also should be noted that the medical forensic audit itself does not exist.

Palabras llave : medical records; medical-legal documents; medical audit and forensic expertise.