The clinical history is a document of special protection and relevance within medical treatment and the patient-physician relationship, since it collects the necessary data regarding diagnosis, treatment, and evolution. Consequently, its purpose is not to serve as a means of proof, but as a record of all medical care received by the patient and prescribed by the treating physician.
In judicial proceedings, the clinical history has special relevance as a means of proof by allowing the health impairment to be evidenced by showing the specific event, in this case of the worker. However, said history alone is not considered sufficient evidence to demonstrate the existence of a work accident or occupational disease, since to prove that type of accident or disease, additional evidentiary means are required to identify that the ailment or harm of the patient-worker recorded in the clinical history was a consequence of a work accident or occupational disease, thus demonstrating the causal link.
Source: SL 2262-2022, Justice Luis Benedicto Herrera Díaz.