Download DOCUMENTO GUIA PARA REALIZAR LA ASESORIA EXTERNA

DOCUMENTO
GUIA PARA
REALIZAR LA
ASESORIA
EXTERNA
CONAMED
Ley
Conjunto de normas jurídicas de observancia general
y obligatorias, que tienen por objeto regular las
conductas entre particulares y entre estos y el Estado,
para garantizar el orden social
ASESORÍA EXTERNA
Nombre del Asesor:______________________________________________________________
Especialidad:____________________
Cuestionario:___________________________________________________________________
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Fecha en que se solicita la asesoría:_____________________________
Plazo que se fijó para la entrega de su informe: ___________________
Fecha de entrega a CECAMED: ______________________________
Consideraciones: ________________________________________________________________
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Conclusiones: __________________________________________________________________
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BIBLIOGRAFÍA
AUTOR
TÍTULO
EDITORIAL
EDICIÓN Y
AÑO
PÁGINA
Análisis:______________________________________________________________________
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EVALUACIÓN DE ATENCIÓN MÉDICO-QUIRÚRGICA
A.- Razonamiento clínico:
1.- Estudio clínico:
completo__________
incompleto____________
2.- Deficiencias:
Interrogatorio_____
Exploración física_____
Otros_____
Especificar:______________________________________________________________
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3.- Pruebas de diagnóstico necesarias:
Completas_____
Especificar______________________________________________________________
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Sustentación:_____________________________________________________________
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Incompletas:_____
Especificar:______________________________________________________________
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Sustentación:_____________________________________________________________
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Riesgo en procedimientos especiales:
Riesgos en procedimientos de diagnósticos:________________________
Riesgo anestésico:____________________
Riesgo quirúrgico:____________________
Sustentación:_____________________________________________________________
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Señalar obligaciones de resultados:___________________________________________
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4. Integración de hallazgos clínicos con los resultados de las pruebas:
Integración correcta:________
Especificar:______________________________________________________________
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Integración incorrecta:________
Especificar:______________________________________________________________
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Sustentación:_____________________________________________________________
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5. Diagnóstico:
¿Hubo diagnóstico?
Si_______
No_______
Diagnóstico:_____________________________________________________________
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Correcto:___________
Incorrecto:__________
Sustentación:_____________________________________________________________
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¿Hubo diagnóstico diferencial?
Si_______
No_______
Especificar:______________________________________________________________
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6. Alternativas de tratamiento conforme a las circunstancias del caso:
Especificar:
NUM.
ALTERNATIVAS DISPONIBLES
7. Valoración de Alternativas:
NUM.
RIESGOS
BENEFICIOS
OBSERVACIONES
8. Valoración del riesgo-beneficio:__________________________________________________
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9. Elección:____________________________________________________________________
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10. Factores limitantes:___________________________________________________________
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11. Evaluación de la libertad prescriptiva:
Criterio médico-quirúrgico:_________________________________________________
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12. Limitaciones institucionales:___________________________________________________
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Disponibilidad de recursos:________________________________________________________
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13. Necesidad de modificación del tratamiento:________________________________________
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14. Condicionamiento y preferencias del paciente:_____________________________________
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B.- Consentimiento bajo información:
Inexistencia del consentimiento:__________________
Se suscribieron condiciones inaceptables y desventajosas:_____________
Se acredita solo consentimiento verbal:_______________
Se omitió consentimiento escrito, en casos obligatorios:_______________
Especificar:
NUM
OMISIONES
La carta de consentimiento bajo información se suscribió con deficiencias:______
Se obtuvo consentimiento escrito con arreglo a derecho:______
C.- Tratamiento:
Clasificación:
Tipo
1. De urgencia
2. De elección
3. De competencia
Indicador
Idoneidad:
¿Se trataba de tratamiento de elección?
¿Se trataba de tratamiento de amplio espectro?
¿El tratamiento fue oportuno?
Tipo
A. Preventivo
B. Curativo
C. Rehabilitatorio
Si________
Si________
Si________
Indicador
No_________
No_________
No_________
Especificar:____________________________________________________________________
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¿Se consideraron sinergias y antagonismos farmacológicos?_____________________________
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18. Señalar obligaciones de medios o de diligencias del personal de salud:
a) Personal médico.NOMBRE
OBLIGACIONES
OBSERVACIONES
b) Personal de enfermería.-
NOMBRE
OBLIGACIONES
OBSERVACIONES
OBLIGACIONES
OBSERVACIONES
c) Personal paramédico.-
NOMBRE
19. Señalar obligaciones de supervisión y personal responsable:___________________________
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Especificar:____________________________________________________________________
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20. Evaluación de obligaciones de seguridad:_________________________________________
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21. ¿Eran exigibles algunos resultados?
Si_______
No_______
Especificar:______________________________________________________________
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22. ¿Se modificó la conducta terapéutica conforme a la evolución y necesidades del paciente?
Si_______
No________
Especificar:______________________________________________________________
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D). Obligaciones del establecimiento:
NUM.
ESPECIFICAR LAS OBLIGACIONES
Evaluación:______________________________________________________________
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1. Se dio información completa al paciente a lo largo de su tratamiento?
Si______ No______
Especificar:______________________________________________________________
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2. Capacidad de respuesta institucional:______________________________________________
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3. ¿Existió y estuvo disponible la infraestructura necesaria?
Si_______
No_______
Especificar:______________________________________________________________
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4. Era necesaria la referencia del paciente a un establecimiento de mayor complejidad?
Si________
No________
Especificar:______________________________________________________________
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E) Intervención de otros profesionales y problemas de tráfico:
¿El personal tratante debió abstenerse de continuar la atención y derivar al paciente a un
especialista?
Si_______
No________
Especificar:______________________________________________________________
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¿Debió existir interconsulta a otros profesionales?
Si_______ No______
Especificar:______________________________________________________________
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Debió hacerse intervenir, además del personal tratante a otros especialistas en el
tratamiento?
Si________
No_______
Especificar:______________________________________________________________
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¿Se refirió adecuadamente al paciente?
Si_______ No_______
Especificar:______________________________________________________________
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¿Se emitió alta voluntaria con arreglo a las disposiciones aplicables? Si_____ No_____
Especificar:______________________________________________________________
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¿Se emitió responsiva con arreglo a la ley?
Si______ No______
Especificar:______________________________________________________________
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¿Se incumplieron las obligaciones contraídas en la responsiva?
Si______ No______
Especificar:______________________________________________________________
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¿Se entregaron adecuadamente turnos críticos?
Si_____ No______
Especificar:______________________________________________________________
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¿Existen evidencias de carencia de personal?
Si_____ No______
Especificar:______________________________________________________________
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¿Existen omisiones imputables al personal hospitalario?
Si______ No______
Especificar:______________________________________________________________
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Señalar carencias, o limitaciones de auxiliares de diagnóstico y tratamiento:___________
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EVALUACIÓN DE RESPONSABILIDAD:
A) CONDUCTA MÉDICA:
1. El personal médico mostró capacidad de previsión:
Si_____
Especificar:
NOMBRE
CAUSA
2. El personal médico cumplió voluntariamente las disposiciones jurídicas:
Especificar:
NOMBRE
CAUSA
3. El personal actuó contrariando de manera genérica normas jurídicas:
Especificar:
NOMBRE
CAUSA
No_____
4. El personal médico actuó sin la previsión necesaria:
Especificar:
NOMBRE
CAUSA
5. El personal dejó de lado reglamentos o deberes a su cargo cuando las condiciones eran
previsibles:
Especificar:
NOMBRE
CAUSA
6. El personal actuó con desconocimiento o falta de habilidad o destreza:
Especificar:
NOMBRE
CAUSA
7. El personal omitió instrucciones precisas y/o supervisión adecuada:
Especificar:
NOMBRE
CAUSA
B) NEXO CAUSAL:
1. Atendiendo a la historia natural de la enfermedad el padecimiento ocasionaba daños:
Si_______ No________
Especificar:__________________________________________________________
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2. ¿El evento adverso era de esperarse en ausencia de dolo, negligencia o impericia?
Si______ No______
Especificar:__________________________________________________________
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3. ¿El evento adverso fue originado por yatrogenia o yatropatogenia?
Yatrogenia_____________ Yatropatogenia ____________
Especificar:__________________________________________________________
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4. ¿El evento adverso se debió a una acción voluntaria o contribuyente del enfermo o de
terceros?
Si______ No_______
Especificar:__________________________________________________________
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5. ¿El evento adverso se debió a idiosincrasia u otras causas intrínsicas del paciente?
Si_______ No________
Especificar:__________________________________________________________
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6. ¿El evento adverso se debió a un accidente en el que no intervino personal de salud ni alguno
de los elementos anteriores?
Si______ No_______
Especificar:__________________________________________________________
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C) FALLAS DE ORIGEN MEDICO:
1. Tratamientos no controlados:
Especificar:__________________________________________________________
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2. Medicamentos no tolerados:
Especificar:__________________________________________________________
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Tratamientos inadecuados por razones técnicas (especialmente quirúrgicos):
Especificar:____________________________________________________________________
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Tratamientos inadecuados por razones económicas:
Tratamientos baratos
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Tratamientos ausentes
_________
Tratamientos postergados
_________
Especificar:__________________________________________________________
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4. Ausencia o inoperancia de la medicina rehabilitatoria:
Especificar:___________________________________________________________
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5. Medicamentos fuera de los límites de la necesidad terapéutica:
Calidad_______ Cantidad________
Especificar:___________________________________________________________
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6. Ausencia de registro de datos:
Especificar:___________________________________________________________
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7. Ignorancia de los antecedentes del paciente:
Especificar:___________________________________________________________
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8. Falta de consultas y tratamientos de especialistas:
Especificar:___________________________________________________________
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9. Falta de internamiento oportuno:
Especificar:___________________________________________________________
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10. Exámenes rápidos:
Especificar:___________________________________________________________
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11. Abuso de medicina invasiva:
Especificar:___________________________________________________________
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12. Negativa de atención injustificada:
Especificar:___________________________________________________________
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13. Aspectos adversos originados por alta prematura:
Especificar:___________________________________________________________
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14. Lesiones o perjuicios debidos a vigilancia inadecuada:
Especificar:___________________________________________________________
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15. Violación al secreto profesional:
Especificar:___________________________________________________________
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16. Ensañamiento terapéutico:
Especificar:___________________________________________________________
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D) FALLAS DE ORIGEN HOSPITALARIO:
1. Negativa de admisión sin justificar el impedimento:
Especificar:___________________________________________________________
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2. Perjuicios derivados del alta prematura:
Especificar:___________________________________________________________
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3. Lesiones o perjuicios durante el internamiento, producto de vigilancia inadecuada:
Especificar:___________________________________________________________
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4. Accidentes durante el internamiento (caída de cama o camilla, quemaduras, etc.):
Propiamente accidentes
Debidos a falta de vigilancia
____________
____________
Especificar:___________________________________________________________
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5. Falta de mantenimiento de equipo o instrumental:
Especificar:______________________________________________________________
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6. Instalaciones inadecuadas:
Especificar:______________________________________________________________
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7. Error en la administración de medicamentos y soluciones por cambio de la medicación en la
vía o en la dósis:
Especificar:______________________________________________________________
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8. Falta de insumos:
Especificar:______________________________________________________________
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9. Infecciones nosocomiales:
Especificar:______________________________________________________________
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10. Exigencias económicas injustificadas:
Especificar.______________________________________________________________
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11. Condicionamiento de atención por requisitos económicos:
Especificar:______________________________________________________________
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12. Retención indebida de paciente o cadáver:
Especificar:_____________________________________________________________
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13. Manejo abusivo del paciente o ensañamiento terapéutico:
Especificar:______________________________________________________________
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14. Maltrato al paciente, discriminación y afectación de su dignidad:
Especificar:______________________________________________________________
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15. Insuficiencia de personal:
Especificar:______________________________________________________________
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16. Falta de capacitación al personal:
Especificar:______________________________________________________________
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17. Falta de supervisión al personal:
Especificación:___________________________________________________________
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18. Deficiencias en el llenado del expediente clínico:
Especificación:___________________________________________________________
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19. Deficiencias en servicios auxiliares de diagnóstico y tratamiento:
Especificar:______________________________________________________________
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20. Deficiencias en los servicios de urgencias, terapia intensiva y quirófano:
Especificar:______________________________________________________________
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Señalar desabasto de insumos para la salud:____________________________________
______________________________________________________________________________
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¿Existió negativa de servicios?
TIPO DE SERVICIOS
NEGADOS
SI
NO
Preventivos
Curativos
Rehabilitatorios
Especificar:______________________________________________________________
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¿Existió negativa de insumos?
Si______ No______
Especificar:______________________________________________________________
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¿Existen problemas de traslado o en unidades móviles?
Si______ No_____
Especificar:______________________________________________________________
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¿Existió descortesía o maltrato del personal hospitalario?
Si______ No_____
Especificar:______________________________________________________________
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Determinar incumplimiento en obligaciones de tráfico:
Especificar:______________________________________________________________
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21. Deficiencias en unidades móviles:_______________________________________________
Especificar:______________________________________________________________
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22. Deficiencias en la información al paciente y su representación legal.
Especificar:______________________________________________________________
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23. Manejo indebido del alta voluntaria, egreso hospitalario y certificación de la defunción:
Especificar:______________________________________________________________
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24. Actos irregulares en investigación clínica o en necropsia hospitalaria:
Especificar:______________________________________________________________
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25. Actos irregulares en la disposición de órganos y tejidos:
Especificar:______________________________________________________________
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E. CONCLUSIONES Y RECOMENDACIONES
CONCLUSIONES
Especificar:______________________________________________________________
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