{"id":1685,"date":"2026-07-11T04:03:35","date_gmt":"2026-07-11T04:03:35","guid":{"rendered":"https:\/\/itaca.ai\/?page_id=1685"},"modified":"2026-07-11T10:10:43","modified_gmt":"2026-07-11T10:10:43","slug":"reglas","status":"publish","type":"page","link":"https:\/\/itaca.ai\/en\/notas-clinicas-ia\/reglas\/","title":{"rendered":"Reglas para notas cl\u00ednicas: ejemplos para una documentaci\u00f3n consistente"},"content":{"rendered":"<div class=\"wp-block-group alignfull has-background-background-color has-background is-layout-constrained wp-container-core-group-is-layout-dbce86ea wp-block-group-is-layout-constrained\" style=\"padding-top:6rem;padding-right:var(--wp--preset--spacing--50);padding-bottom:5rem;padding-left:var(--wp--preset--spacing--50)\">\n<div class=\"wp-block-columns are-vertically-aligned-center is-layout-flex wp-container-core-columns-is-layout-9a702098 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-vertically-aligned-center fotawp-fade-up is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:54%\">\n<h5 class=\"wp-block-heading has-primary-color has-text-color has-small-font-size\" style=\"margin-bottom:18px;font-style:normal;font-weight:700;letter-spacing:4px;text-transform:uppercase\">Documentaci\u00f3n consistente<\/h5>\n\n\n\n<h1 class=\"wp-block-heading has-heading-color-color has-text-color\" style=\"margin-bottom:24px;font-size:56px;font-style:normal;font-weight:700;line-height:1.08\">Reglas para notas cl\u00ednicas y documentaci\u00f3n consistente<\/h1>\n\n\n\n<p class=\"has-text-color wp-block-paragraph\" style=\"color:#5f5f5f;margin-bottom:2.2rem;font-size:18px;line-height:1.8\">Itaca ayuda a las cl\u00ednicas a documentar con criterios comunes: plantillas, reglas de nota y revisi\u00f3n profesional mantienen la estructura clara sin quitar control al m\u00e9dico que aprueba la nota final.<\/p>\n\n\n\n<div class=\"wp-block-buttons fotawp-slide-up is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button is-style-button-hover-secondary-bgcolor\"><a class=\"wp-block-button__link has-foregound-alt-color has-heading-color-background-color has-text-color has-background wp-element-button\" href=\"https:\/\/app.itaca.pro\/sign_up?locale=en\" style=\"border-radius:100px;padding-top:1rem;padding-right:2rem;padding-bottom:1rem;padding-left:2rem\">Try Ithaca<\/a><\/div>\n\n\n\n<div class=\"wp-block-button is-style-button-hover-secondary-bgcolor\"><a class=\"wp-block-button__link has-heading-color-color has-background-alt-background-color has-text-color has-background wp-element-button\" href=\"\/en\/clinical-notes-ai\/templates\/\" style=\"border-radius:100px;padding-top:1rem;padding-right:2rem;padding-bottom:1rem;padding-left:2rem\">Ver plantillas<\/a><\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-vertically-aligned-center fotawp-zoom-in-up is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:46%\">\n<div class=\"wp-block-group is-style-fotawp-boxshadow-medium has-background is-layout-constrained wp-container-core-group-is-layout-0fbfd72b wp-block-group-is-layout-constrained\" style=\"border-radius:20px;background-color:#ffffff;padding-top:18px;padding-right:18px;padding-bottom:18px;padding-left:18px\">\n<figure class=\"wp-block-image size-large\"><img data-recalc-dims=\"1\" decoding=\"async\" width=\"1024\" height=\"640\" loading=\"lazy\" src=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinic-workflow-illustration.png?resize=1024%2C640&#038;ssl=1\" alt=\"Equipo m\u00e9dico usando reglas de documentaci\u00f3n cl\u00ednica en Itaca\" class=\"wp-image-1485\" srcset=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinic-workflow-illustration.png?resize=1024%2C640&amp;ssl=1 1024w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinic-workflow-illustration.png?resize=300%2C188&amp;ssl=1 300w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinic-workflow-illustration.png?resize=768%2C480&amp;ssl=1 768w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinic-workflow-illustration.png?resize=1536%2C961&amp;ssl=1 1536w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinic-workflow-illustration.png?resize=18%2C12&amp;ssl=1 18w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinic-workflow-illustration.png?w=1586&amp;ssl=1 1586w\" sizes=\"auto, (max-width: 1000px) 100vw, 1000px\" \/><\/figure>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-group alignfull has-background-alt-background-color has-background is-layout-constrained wp-container-core-group-is-layout-102bcdd1 wp-block-group-is-layout-constrained\" style=\"padding-top:6rem;padding-right:var(--wp--preset--spacing--40);padding-bottom:6rem;padding-left:var(--wp--preset--spacing--40)\">\n<h5 class=\"wp-block-heading has-text-align-center has-primary-color has-text-color has-small-font-size\" style=\"font-style:normal;font-weight:700;letter-spacing:4px;text-transform:uppercase\">Plantillas, reglas y criterio<\/h5>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center\" style=\"font-size:46px;font-style:normal;font-weight:700;line-height:1.18\">Documentaci\u00f3n consistente sin quitar control cl\u00ednico<\/h2>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-d2c4d4f7 wp-block-columns-is-layout-flex\" style=\"margin-top:54px\">\n<div class=\"wp-block-column fotawp-fade-up is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group is-style-fotawp-boxshadow-hover has-background is-layout-constrained wp-container-core-group-is-layout-2fcb7877 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#dfd3ff;padding-top:40px;padding-right:36px;padding-bottom:40px;padding-left:36px\">\n<figure class=\"wp-block-image size-full is-resized\"><img data-recalc-dims=\"1\" decoding=\"async\" width=\"100\" height=\"100\" loading=\"lazy\" src=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/template.png?resize=100%2C100&#038;ssl=1\" alt=\"Plantilla cl\u00ednica\" class=\"wp-image-2785\" style=\"width:64px\" srcset=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/template.png?w=100&amp;ssl=1 100w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/template.png?resize=12%2C12&amp;ssl=1 12w\" sizes=\"auto, (max-width: 100px) 100vw, 100px\" \/><\/figure>\n\n\n\n<h3 class=\"wp-block-heading\">Plantilla<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Define la estructura esperada para cada tipo de consulta, especialidad o seguimiento.<\/p>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column fotawp-fade-up is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group is-style-fotawp-boxshadow-hover has-background is-layout-constrained wp-container-core-group-is-layout-2fcb7877 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#ffefc7;padding-top:40px;padding-right:36px;padding-bottom:40px;padding-left:36px\">\n<figure class=\"wp-block-image size-full is-resized\"><img data-recalc-dims=\"1\" decoding=\"async\" width=\"100\" height=\"100\" loading=\"lazy\" src=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/document.png?resize=100%2C100&#038;ssl=1\" alt=\"Regla de documentaci\u00f3n\" class=\"wp-image-2937\" style=\"width:64px\" srcset=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/document.png?w=100&amp;ssl=1 100w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/document.png?resize=12%2C12&amp;ssl=1 12w\" sizes=\"auto, (max-width: 100px) 100vw, 100px\" \/><\/figure>\n\n\n\n<h3 class=\"wp-block-heading\">Regla de nota<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Ayuda a mantener secciones, lenguaje, pendientes y criterios comunes para todo el equipo.<\/p>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column fotawp-fade-up is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group is-style-fotawp-boxshadow-hover has-background is-layout-constrained wp-container-core-group-is-layout-2fcb7877 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#c7f8ff;padding-top:40px;padding-right:36px;padding-bottom:40px;padding-left:36px\">\n<figure class=\"wp-block-image size-full is-resized\"><img data-recalc-dims=\"1\" decoding=\"async\" width=\"100\" height=\"100\" loading=\"lazy\" src=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/medical-doctor-1.png?resize=100%2C100&#038;ssl=1\" alt=\"Criterio profesional\" class=\"wp-image-2939\" style=\"width:64px\" srcset=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/medical-doctor-1.png?w=100&amp;ssl=1 100w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/medical-doctor-1.png?resize=12%2C12&amp;ssl=1 12w\" sizes=\"auto, (max-width: 100px) 100vw, 100px\" \/><\/figure>\n\n\n\n<h3 class=\"wp-block-heading\">Criterio cl\u00ednico<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Permanece en manos del profesional que revisa, corrige, aprueba y firma la nota final.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-group alignfull has-background is-layout-constrained wp-container-core-group-is-layout-3bf755a6 wp-block-group-is-layout-constrained\" style=\"background-color:#ffffff;padding-top:80px;padding-right:24px;padding-bottom:80px;padding-left:24px\">\n<div class=\"wp-block-columns alignwide are-vertically-aligned-center is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-vertically-aligned-center is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:46%\">\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" decoding=\"async\" width=\"1024\" height=\"640\" loading=\"lazy\" src=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinical-notes-soap-illustration.png?resize=1024%2C640&#038;ssl=1\" alt=\"Profesional revisando una nota cl\u00ednica con reglas de documentaci\u00f3n\" class=\"wp-image-1487\" srcset=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinical-notes-soap-illustration.png?resize=1024%2C640&amp;ssl=1 1024w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinical-notes-soap-illustration.png?resize=300%2C188&amp;ssl=1 300w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinical-notes-soap-illustration.png?resize=768%2C480&amp;ssl=1 768w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinical-notes-soap-illustration.png?resize=1536%2C961&amp;ssl=1 1536w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinical-notes-soap-illustration.png?resize=18%2C12&amp;ssl=1 18w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/07\/itaca-clinical-notes-soap-illustration.png?w=1586&amp;ssl=1 1586w\" sizes=\"auto, (max-width: 1000px) 100vw, 1000px\" \/><\/figure>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-vertically-aligned-center is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:54%\">\n<p class=\"has-primary-color has-text-color has-small-font-size wp-block-paragraph\">REGLAS \u00daTILES EN LA PR\u00c1CTICA<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Estandarice lo importante sin volver r\u00edgida la atenci\u00f3n<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Las reglas ayudan a separar motivo, hallazgos y plan; a mantener visible la informaci\u00f3n pendiente; y a evitar que datos no documentados se presenten como hechos. El profesional conserva el criterio cl\u00ednico y la aprobaci\u00f3n final.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Las plantillas ordenan la estructura de cada formato.<\/li>\n\n\n\n<li>Las reglas reducen variaciones innecesarias entre profesionales.<\/li>\n\n\n\n<li>La revisi\u00f3n cl\u00ednica confirma que el borrador corresponde a la atenci\u00f3n real.<\/li>\n<\/ul>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button is-style-button-hover-secondary-bgcolor\"><a class=\"wp-block-button__link has-foregound-alt-color has-heading-color-background-color has-text-color has-background wp-element-button\" href=\"https:\/\/itaca.ai\/en\/clinical-notes-ai\/templates\/\">Ver plantillas cl\u00ednicas<\/a><\/div>\n\n\n\n<div class=\"wp-block-button is-style-button-hover-secondary-bgcolor\"><a class=\"wp-block-button__link has-heading-color-color has-background-alt-background-color has-text-color has-background wp-element-button\" href=\"https:\/\/itaca.ai\/en\/new-features\/signed-clinical-notes-medical-records\/\">Ver firma y addendas<\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div style=\"height:72px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-group alignfull is-layout-constrained wp-container-core-group-is-layout-eb8a6aaa wp-block-group-is-layout-constrained\" style=\"padding-top:24px;padding-right:24px;padding-bottom:80px;padding-left:24px\">\n<p class=\"has-text-align-center has-primary-color has-text-color has-small-font-size wp-block-paragraph\">BIBLIOTECA DE REGLAS<\/p>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center\">Reglas cl\u00ednicas disponibles, organizadas por categor\u00eda<\/h2>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">Estos son ejemplos de la biblioteca de Itaca. Cada regla se aplica solo cuando la informaci\u00f3n necesaria est\u00e1 documentada; no calcula, recomienda ni completa datos por su cuenta.<\/p>\n\n\n\n<div class=\"wp-block-columns alignwide is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#ffefc7;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Cardiovascular y metab\u00f3lico<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Categor\u00eda de riesgo cardiovascular:<\/strong> clasifica bajo, moderado, alto o muy alto solo con los criterios de la visita; no inventa una puntuaci\u00f3n si faltan datos.<\/li>\n\n\n\n<li><strong>Control de hipertensi\u00f3n:<\/strong> documenta controlada o no controlada \u00fanicamente cuando las mediciones o la discusi\u00f3n cl\u00ednica lo sustentan.<\/li>\n\n\n\n<li><strong>Aspirina en prevenci\u00f3n primaria:<\/strong> registra riesgo cardiovascular y de sangrado cuando esa conversaci\u00f3n ocurri\u00f3.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#c7f8ff;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Perioperative risk<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Riesgo perioperatorio RCRI \/ Lee:<\/strong> calcula el \u00edndice solo cuando los seis predictores est\u00e1n documentados expl\u00edcitamente.<\/li>\n\n\n\n<li><strong>Riesgo perioperatorio AUB-HAS2:<\/strong> reporta puntuaci\u00f3n y grupo de riesgo solo si los elementos necesarios est\u00e1n claros; no asume ausencias.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-columns alignwide is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#dfd3ff;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Mental health<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Vigilancia de activaci\u00f3n con ISRS\/IRSN:<\/strong> menciona ansiedad, insomnio, agitaci\u00f3n o ideas suicidas a vigilar cuando se inici\u00f3 o aument\u00f3 el medicamento y fue cl\u00ednicamente relevante.<\/li>\n\n\n\n<li><strong>Riesgos de benzodiacepinas:<\/strong> documenta justificaci\u00f3n, duraci\u00f3n prevista y riesgos cuando se prescribieron o continuaron.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#ffefc7;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Medication safety<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Advertencia con clonazepam:<\/strong> incorpora una nota breve de seguridad cuando corresponde a la visita.<\/li>\n\n\n\n<li><strong>Contexto de seguridad con opioides:<\/strong> registra duraci\u00f3n, sedaci\u00f3n, alcohol u otros sedantes, naloxona o seguimiento solo cuando esos temas se discutieron.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-columns alignwide is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#c7f8ff;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Pediatr\u00eda y cuidado familiar<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Contexto de dosis pedi\u00e1trica:<\/strong> incluye peso y base de dosificaci\u00f3n, como mg\/kg, si ambos se mencionaron; no ajusta dosis de forma independiente.<\/li>\n\n\n\n<li><strong>Precauciones en fiebre pedi\u00e1trica:<\/strong> agrega hidrataci\u00f3n, alertas y seguimiento en lenguaje sencillo cuando corresponden a la visita.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#dfd3ff;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Salud de la mujer<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Alertas en anticoncepci\u00f3n hormonal combinada:<\/strong> documenta los factores de riesgo relevantes discutidos, como migra\u00f1a con aura, tabaquismo, hipertensi\u00f3n, TEV previo o posparto; no presume que est\u00e9n ausentes.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-columns alignwide is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#ffefc7;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Adultos mayores y cronicidad<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Riesgo de ca\u00eddas:<\/strong> resume factores presentes, como ca\u00eddas recientes, marcha inestable, s\u00edntomas ortost\u00e1ticos o sedantes.<\/li>\n\n\n\n<li><strong>TFGe por CKD-EPI 2021:<\/strong> se estima solo con edad adulta, sexo, creatinina y unidades claras; si el laboratorio ya la reporta, se prioriza ese valor.<\/li>\n\n\n\n<li><strong>\u00cdndice FIB-4 de fibrosis hep\u00e1tica:<\/strong> se calcula solo con edad, AST, ALT y plaquetas; se presenta como \u00edndice de cribado, no como diagn\u00f3stico.<\/li>\n\n\n\n<li><strong>Consideraciones de dosis renal:<\/strong> se mencionan cuando funci\u00f3n renal y medicamento relevante se discutieron o est\u00e1n claramente sustentados.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-group has-background is-layout-constrained wp-container-core-group-is-layout-52be2e83 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#c7f8ff;padding-top:30px;padding-right:30px;padding-bottom:30px;padding-left:30px\">\n<h3 class=\"wp-block-heading\">Format and terminology<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>T\u00e9rmino preferido acetaminof\u00e9n:<\/strong> usa acetaminof\u00e9n cuando aparece paracetamol.<\/li>\n\n\n\n<li><strong>Ortograf\u00eda preferida:<\/strong> corrige Floxetina a Fluoxetina en el nombre del medicamento.<\/li>\n\n\n\n<li><strong>Formato de presi\u00f3n arterial:<\/strong> normaliza el valor como XXX\/XX mmHg y mantiene la interpretaci\u00f3n aparte.<\/li>\n\n\n\n<li><strong>Evitar consejos gen\u00e9ricos:<\/strong> en instrucciones para paciente, prioriza pasos, alertas y tiempos de seguimiento concretos.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-group alignfull has-background is-layout-constrained wp-container-core-group-is-layout-02da18d0 wp-block-group-is-layout-constrained\" style=\"background-color:#f8f7f4;padding-top:72px;padding-right:24px;padding-bottom:72px;padding-left:24px\">\n<div class=\"wp-block-columns alignwide are-vertically-aligned-center is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-vertically-aligned-center is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:48%\">\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" decoding=\"async\" width=\"1448\" height=\"1086\" loading=\"lazy\" src=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/06\/Generated-image-2.png?resize=1448%2C1086&#038;ssl=1\" alt=\"M\u00e9dica atendiendo mientras Itaca organiza documentaci\u00f3n cl\u00ednica\" class=\"wp-image-1411\" srcset=\"https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/06\/Generated-image-2.png?w=1448&amp;ssl=1 1448w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/06\/Generated-image-2.png?resize=300%2C225&amp;ssl=1 300w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/06\/Generated-image-2.png?resize=1024%2C768&amp;ssl=1 1024w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/06\/Generated-image-2.png?resize=768%2C576&amp;ssl=1 768w, https:\/\/i0.wp.com\/itaca.ai\/wp-content\/uploads\/2026\/06\/Generated-image-2.png?resize=16%2C12&amp;ssl=1 16w\" sizes=\"auto, (max-width: 1000px) 100vw, 1000px\" \/><\/figure>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-vertically-aligned-center is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:52%\">\n<p class=\"has-primary-color has-text-color has-small-font-size wp-block-paragraph\">ALCANCE REAL DE LAS REGLAS<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">La biblioteca distingue d\u00f3nde debe aplicarse cada regla<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Las reglas de la biblioteca ya indican su alcance. Esto evita reutilizar una regla cl\u00ednica como instrucci\u00f3n para paciente, o llevar una advertencia de seguridad a un contexto donde no fue discutida.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Notas cl\u00ednicas:<\/strong> riesgo cardiovascular, control de hipertensi\u00f3n, RCRI\/Lee, AUB-HAS2, anticoncepci\u00f3n hormonal, ca\u00eddas, TFGe, FIB-4 y consideraciones de dosis renal.<\/li>\n\n\n\n<li><strong>Instrucciones para paciente:<\/strong> precauciones ante fiebre pedi\u00e1trica y eliminaci\u00f3n de consejos gen\u00e9ricos de bajo valor.<\/li>\n\n\n\n<li><strong>Ambas:<\/strong> activaci\u00f3n con ISRS\/IRSN, riesgos de benzodiacepinas, clonazepam, opioides, terminolog\u00eda de medicamentos y formato de presi\u00f3n arterial.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Para equipos, estas reglas se pueden combinar con <a href=\"https:\/\/itaca.ai\/en\/clinical-notes-ai\/templates\/\">plantillas cl\u00ednicas reutilizables<\/a> y con el <a href=\"https:\/\/itaca.ai\/en\/software-for-clinics\/\">flujo de documentaci\u00f3n compartida<\/a> de Itaca.<\/p>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button is-style-button-hover-secondary-bgcolor\"><a class=\"wp-block-button__link has-foregound-alt-color has-heading-color-background-color has-text-color has-background wp-element-button\" href=\"https:\/\/calendly.com\/itaca-ai\/clinical-conversation\">Revisar reglas para mi cl\u00ednica<\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-group alignfull is-layout-constrained wp-container-core-group-is-layout-17d40d9b wp-block-group-is-layout-constrained\" style=\"padding-top:80px;padding-right:24px;padding-bottom:72px;padding-left:24px\">\n<p class=\"has-text-align-center has-primary-color has-text-color has-small-font-size wp-block-paragraph\">FREQUENTLY ASKED QUESTIONS<\/p>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center\">Preguntas sobre la biblioteca de reglas<\/h2>\n\n\n\n<details class=\"wp-block-details is-layout-flow wp-block-details-is-layout-flow\"><summary>\u00bfLas reglas de la biblioteca se aplican siempre?<\/summary>\n<p class=\"wp-block-paragraph\">No. Cada una se aplica solo cuando el caso contiene la informaci\u00f3n o la conversaci\u00f3n que la regla requiere. Si falta un dato, la regla no lo completa ni lo infiere.<\/p>\n<\/details>\n\n\n\n<details class=\"wp-block-details is-layout-flow wp-block-details-is-layout-flow\"><summary>\u00bfUna regla puede calcular un riesgo cl\u00ednico?<\/summary>\n<p class=\"wp-block-paragraph\">Las reglas de RCRI\/Lee, AUB-HAS2, TFGe y FIB-4 calculan o clasifican solo cuando cuentan con los datos expl\u00edcitos y las unidades necesarias. Si falta informaci\u00f3n, lo indican.<\/p>\n<\/details>\n\n\n\n<details class=\"wp-block-details is-layout-flow wp-block-details-is-layout-flow\"><summary>\u00bfQu\u00e9 reglas se pueden usar para instrucciones al paciente?<\/summary>\n<p class=\"wp-block-paragraph\">La biblioteca incluye precauciones para fiebre pedi\u00e1trica y una regla para sustituir consejos gen\u00e9ricos por pasos, se\u00f1ales de alarma e instrucciones de seguimiento concretas.<\/p>\n<\/details>\n\n\n\n<details class=\"wp-block-details is-layout-flow wp-block-details-is-layout-flow\"><summary>\u00bfLas reglas reemplazan la revisi\u00f3n del profesional?<\/summary>\n<p class=\"wp-block-paragraph\">No. Itaca prepara un borrador revisable. El profesional confirma que el contenido corresponde a la atenci\u00f3n real y conserva la decisi\u00f3n de aprobar o firmar.<\/p>\n<\/details>\n<\/div>\n\n\n\n<div class=\"wp-block-group alignfull has-background is-layout-constrained wp-container-core-group-is-layout-624d65b7 wp-block-group-is-layout-constrained\" style=\"border-radius:8px;background-color:#ffefc7;padding-top:48px;padding-right:48px;padding-bottom:48px;padding-left:48px\">\n<div class=\"wp-block-columns alignwide are-vertically-aligned-center is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-vertically-aligned-center is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:68%\">\n<h2 class=\"wp-block-heading\">Haga que cada nota sea m\u00e1s f\u00e1cil de revisar y retomar<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Conozca c\u00f3mo Itaca combina documentaci\u00f3n cl\u00ednica con IA, plantillas y reglas para ayudar a su equipo a trabajar con un est\u00e1ndar compartido.<\/p>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-vertically-aligned-center is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:32%\">\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button is-style-button-hover-secondary-bgcolor\"><a class=\"wp-block-button__link has-foregound-alt-color has-heading-color-background-color has-text-color has-background wp-element-button\" href=\"https:\/\/app.itaca.pro\/sign_up?locale=en\">Try Ithaca<\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>Reglas para notas cl\u00ednicas que estandarizan c\u00f3mo documentar riesgos, medicamentos, c\u00e1lculos, terminolog\u00eda, instrucciones y seguimiento sin reemplazar la revisi\u00f3n profesional.<\/p>","protected":false},"author":3,"featured_media":0,"parent":1480,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"nf_dc_page":"","slim_seo":{"title":"Reglas para notas cl\u00ednicas: ejemplos y uso | Itaca","description":"Explore la biblioteca de reglas cl\u00ednicas de Itaca: riesgo cardiovascular y perioperatorio, salud mental, medicamentos, pediatr\u00eda, cronicidad y terminolog\u00eda."},"footnotes":""},"class_list":["post-1685","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/pages\/1685","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/comments?post=1685"}],"version-history":[{"count":20,"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/pages\/1685\/revisions"}],"predecessor-version":[{"id":3177,"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/pages\/1685\/revisions\/3177"}],"up":[{"embeddable":true,"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/pages\/1480"}],"wp:attachment":[{"href":"https:\/\/itaca.ai\/en\/wp-json\/wp\/v2\/media?parent=1685"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}