La historia clínica del paciente y el consentimiento informado como medio probatorio en los procesos de responsabilidad médica en Colombia

Abstract

The article analyzes from a jurisprudential and doctrinal perspective the evidentiary nature of the so-called documents, informed consent and clinical history. First, it addresses, from the theory of contracts, the form or forms in which consent is given to generate obligations, which is reflected in the so-called document, informed consent, making an analysis through the study of formats of surgical procedures of different institutions providing health services in Cali, in order to verify their formal and material content. Secondly, it highlights and analyses the contribution made by Colombian jurisprudence through judgments handed down by the Supreme Court of Justice, the Civil Court of Cassation and the Council of State, the Administrative Litigation Chamber, during the period from 2018 to 2019, he has been granted, from the evidentiary point of view, both clinical history and informed consent as a means of as an evidence. Finally, it is important to emphasize that there is no uniformity of concepts on the part of the two corporations analyzed in order to determine if the clinical history and informed consent constitute by themselves convincing and influential evidence in the determination of litigation on the occasion of shortcomings in the preparation of those documents, whereas, when taken together, they constitute a reliable means of proof to be taken into account.