The medical record is the document created by doctors and medical personnel to take control and monitor the health of a person or patient. The files are generated following the medical methodology and respecting the requirements of law that applies depending on each country (or state) of the medical practice1.

Paper based medical record

Traditionally, medical records are paper documents where medical staff reports symptoms and conditions that the patient shows at the consultation. This information is stored through time and contributes in a major way in the prevention, care and cure of diseases.

Nowadays technological advances make evident the need to innovate in the administration of health of patients, migrating from the traditional system of medical records on paper to a computerized system. In addition, this need provides the opportunity to integrate and modernize some other aspects of the operation in the medical sector, such as the administration of resources, personnel management, communication with the client and the management of the corporate image.

1.- The service provided by a doctor or medical group in conjunction with nurses, technicians, laboratory workers and associated personnel, can be called as a medical practice. This practice can be located under the same roof or distributed in a region. This document will use this term to refer to a doctor, clinic, hospital or entity that provides health services through medicine.