Clinical documentation is an essential element in the doctor-patient, repeatedly recognized by our doctrine and jurisprudence as a means to certify the completion by professionals health of the rights recognized, with basic character, the Law 41/2002 of November 14, regulating the Patient Autonomy and Rights and Obligations in the Field of Information and Clinical Documentation and test essential observed behavior by the healthcare professional.
The attention to health documentation, given at the time the General Health Law has made large gains, as reflected, inter alia, Articles 9 and 10 as well as in their development regulations, partly repealed by Law 41/2002 of 14 November.
However, the regulation of clinical documentation has been, after entry into force of the General Health Law, various refinements and extensions carried out by rules and regulations of different rank. For example, Law 15/1999 of 13 December on the Protection of Personal Data describes the data on the health of citizens and sensitive data by establishing a uniquely rigorous rules for procurement, custody and eventual disposal, having been already defending the privacy of health data highlighted by the EU Directive 95/46 of 24 October, in which, in addition to reaffirming the rights and freedoms European citizens, especially their privacy on the information related to your health, says the presence of other general interest such as epidemiological studies, the situations of serious risk to the health of the community, research and clinical trials , etc.
Subsequently, Law 41/2002 of November 14, regulated as a matter of some basic clinical documentation, among which include the document of informed consent, advance directive, medical history, the reported high and issuance of medical certificates, noting, finally, Article 23 of the Act which health professionals addition to the obligations outlined in the field of clinical information, have a duty to complete the protocols, records, reports, statistics and other documentation, or administrative assistance, as they relate to clinical processes involved in, and requiring schools or competent health services and health authorities, including those related to medical research and epidemiological information.
But it's also the obligations of health professionals regarding clinical documentation, technical information, statistical and administrative, not exhausted by the Law 41/2002, 14 November, but other laws, such as the Criminal Procedure Law, Civil Procedure Law, or Law on Legal Regime of Public Administrations and Common Administrative Procedure, imposing certain obligations on healthcare professionals regarding clinical documentation.
Moreover, both the autonomous regions, such as professional associations and the Medical College, through the Code of Ethics and Medical Ethics, have also assisted in the establishment of certain obligations with respect to health documentation.
All of the above set existence of a legal, ethical and deontological widely dispersed with respect to the clinical documentation and a systematic failure, though partly mitigated by the enactment of Law 41/2002 of November 14, both state and regional documentation health.
not forget that health documentation, to the extent that is made by health professionals to facilitate patient care and to comply with those obligations imposed by the various rules of law, poses to those health professionals new and complex problems arising on the one hand, the use of computer systems to store and treat health information and, secondly, by the presence of significant public interest in a democratic society that can justify, in some cases, use of personal data concerning health care of citizens in general interests properly motivated and recognized by laws.
Furthermore, it should be noted that today, health documentation is made with increasing frequency by integrated multidisciplinary teams of professionals in the NHS, so arises the need to consider the rights and obligations that documentation regarding the health of all those subjects that relate to it, that is, the doctors that developed, patients whose care is left to record their personal data and medical and health facilities are responsible for keeping the data on the health of patients. And all this in a legal framework that pays special attention to the defense of individual privacy, as the free exercise of the right to disseminate the information contained in clinical documentation.
Posted in Medical Writing on Thursday, April 14, 2011. Number 1439. Year VII.
The attention to health documentation, given at the time the General Health Law has made large gains, as reflected, inter alia, Articles 9 and 10 as well as in their development regulations, partly repealed by Law 41/2002 of 14 November.
However, the regulation of clinical documentation has been, after entry into force of the General Health Law, various refinements and extensions carried out by rules and regulations of different rank. For example, Law 15/1999 of 13 December on the Protection of Personal Data describes the data on the health of citizens and sensitive data by establishing a uniquely rigorous rules for procurement, custody and eventual disposal, having been already defending the privacy of health data highlighted by the EU Directive 95/46 of 24 October, in which, in addition to reaffirming the rights and freedoms European citizens, especially their privacy on the information related to your health, says the presence of other general interest such as epidemiological studies, the situations of serious risk to the health of the community, research and clinical trials , etc. Subsequently, Law 41/2002 of November 14, regulated as a matter of some basic clinical documentation, among which include the document of informed consent, advance directive, medical history, the reported high and issuance of medical certificates, noting, finally, Article 23 of the Act which health professionals addition to the obligations outlined in the field of clinical information, have a duty to complete the protocols, records, reports, statistics and other documentation, or administrative assistance, as they relate to clinical processes involved in, and requiring schools or competent health services and health authorities, including those related to medical research and epidemiological information.
But it's also the obligations of health professionals regarding clinical documentation, technical information, statistical and administrative, not exhausted by the Law 41/2002, 14 November, but other laws, such as the Criminal Procedure Law, Civil Procedure Law, or Law on Legal Regime of Public Administrations and Common Administrative Procedure, imposing certain obligations on healthcare professionals regarding clinical documentation.
Moreover, both the autonomous regions, such as professional associations and the Medical College, through the Code of Ethics and Medical Ethics, have also assisted in the establishment of certain obligations with respect to health documentation.
All of the above set existence of a legal, ethical and deontological widely dispersed with respect to the clinical documentation and a systematic failure, though partly mitigated by the enactment of Law 41/2002 of November 14, both state and regional documentation health.
not forget that health documentation, to the extent that is made by health professionals to facilitate patient care and to comply with those obligations imposed by the various rules of law, poses to those health professionals new and complex problems arising on the one hand, the use of computer systems to store and treat health information and, secondly, by the presence of significant public interest in a democratic society that can justify, in some cases, use of personal data concerning health care of citizens in general interests properly motivated and recognized by laws.
Furthermore, it should be noted that today, health documentation is made with increasing frequency by integrated multidisciplinary teams of professionals in the NHS, so arises the need to consider the rights and obligations that documentation regarding the health of all those subjects that relate to it, that is, the doctors that developed, patients whose care is left to record their personal data and medical and health facilities are responsible for keeping the data on the health of patients. And all this in a legal framework that pays special attention to the defense of individual privacy, as the free exercise of the right to disseminate the information contained in clinical documentation.
Posted in Medical Writing on Thursday, April 14, 2011. Number 1439. Year VII.
0 comments:
Post a Comment