Zasady prowadzenia dokumentacji medycznej w świetle nowych regulacji prawnych
Principles of medical documentation management in the light of new legislative regulations

Summary/Abstract: According to the Act of 6 November 2008 on the patient rights and the patients’ rights ombudsman, medical entities are obliged to keep patients’ medical documentation. The protection of data in such documents constitutes the main responsibility of medical entity. Information on the patients’ health status comes under the special law regulation as it is classified as sensitive personal data. The article presents the principles of medical documentation management in medical entities in the context of the existing regulations. The authors characterize the composition and division of medical documentation, paying particular attention to the possible forms of these documents − paper and electronic one. The principles of making medical documentation accessible to authorized entities are also discussed in the article.

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