Medical records: reflex of physician-patient relationship

Abstract

The article presents a discussion on the physician-patient relationship, using records for this purpose, taken as an instrument of medical work capable of measuring the quality of the professional relationship. By being a document that logs information related to assistance, research and teaching, it is a communication element between services sectors, the institution, and patients. Based on research in five hospitals in Recife/PE, which shows the existence of
medical records with low-quality in their completion, the study points as possible cause the maintenance of individual and organizational postures that establish distortions in filling up
medical records. Based in the hypothesis that such situations may reflect an excluding autonomy relationship, as well as ethical fragility in physician-patient relationship. This article
discusses, under the light of the contemporary theories, the possible intervenient factors in these relationships, and it concludes pointing to the importance of researches and new
studies that would solve the repercussions in filling up the data contained in medical records.