Dificultades en la acreditación fáctica derivadas del valor probatorio de la historia clínica, en el marco del daño antijurídico ocasionado por acto médico

Abstract

Undoubtedly, the Medical Responsibility occupies an important space within the patrimonial responsibility of the State, in the same sense, this subject has been approached from the doctrine and the academy in multiple opportunities, nevertheless the state of the art allowed to show that little is has investigated in relation to the relevance of the clinical history as evidential means and the difficulties of factual accreditation that could be derived from there, becoming this the research axis for the present study. Therefore, it is proposed to identify the legal and economic effects of the probative deficiency derived from the clinical history on the Colombian State, given its significant probative value within the framework of the responsibility for a medical act, in order to arrive at the conclusions of the present study. makes a broad conceptual and theoretical reference, delving into the set by doctrine, jurisprudence and comparative law. Finding as research conclusions, a great relevance of the clinical history as a documentary evidence and as a significant indication for health medical cases, as well as the identification of ten rules and three subgrades decanted from the hermeneutics of the Third Section of the State Council for the period under study. On the other hand, judicial congestion is outlined, as well as the slowing down of judicial decisions as the main legal effects, and the high fiscal burden as the main economic effect. Finally, the invitation to carry out a similar analysis in the future to validate if the implementation of the electronic medical record allowed to avoid the difficulties in factual accreditation that derive today from the conventional clinical history - of manual completion - leading to a decrease in the sentences against the State in terms of Medical Responsibility.