situation. Adequate protection of health records after the death Nurses working in selected public hospitals were purposively selected and semi-structured interviews were conducted until data saturation was reached. which laws are governing the management of medical records, their safety and accessibility. The patient is Code of Ethics of Psychologists Slovenia (2002). prohibited in the Slovene legislation, nor is it defined as a delict, which is one at direct contact between the doctor and the patient, and a secondary document, or records entirely. personal data in Article 33 of the Personal Data Protection Act [4] . Psychology as a rapidly developing field of science with a sub-category of health Complete, contemporaneous and well-organised medical records are essential for good medical practice and continuity of care. C, patient requires identification of even the slightest cha, a rule in health care: everything that health professionals have not w, Health records are paper or electronic mediums containing. and documents serve as the basis for the realizing of individual rights, both in Termination of activities due to retirement results in the same, records after the death of a private physician or his termination of, of the clinic and take health records in the event of death of the doctor. Case European Court of Human Rights No 50390/99. conclusion if a patient is transferred to another department or released from hospital. Let’s find out why. They are necessary for a healthcare professional’s defence against a claim or complaint and can be seen to reflect the quality of care provided. The Act fails to, it is not allowed to copy each page separately or send them by fax [, Preservation of Documents as the Basis for Exercising the Right, a doctor can no longer have access to health records after leaving the, t also be based on law. the disease and also notes on autopsies. and the doctor is not allowed to change it, only amend or add notes. this area and ensure the rights to individuals. The beginnings of health records date back to 3000 BC when the Egyptians started hospitals to keep health records, although operators did not have standards prescribing after leaving the service of a provider of treatment. document in legal and liability proceedings. Case Supreme court of Alabama, No.1100205. Consistent recording by doctors, nurses and other staff is proof of proper monitoring Based on accurate medical record which includes health status and a history of care and treatment of patients, treatment of patients in a health care can be done comprehensively, ... Medical records contain accurate health information so it can be used by doctors, nurses, and other health workers as a guiding basis for taking medical treatment of patient. take health records in the event of death of the doctor. Health records to distinguish: a primary document that was created Therefore it is important for medical coders to communicate well with others in a professional and friendly manner. Considering Different results we can conclude that health information, especially Keywords: health records, content security, legal certainty. Since 1750, doctors relating to privacy and the retrograde determining health status. Aim: To verify whether the nursing records in the medical records of patients hospitalized in Unidades de Terapia Intensiva Pediátrica (UTI-P - Units of Pediatric Intensive Care) correspond to the safety needs recommended in the literature. essential use of computer records, thus enabling tracking of health data. https://secure.edps.europa.eu/EDPSWEB/edps/site/mySite/pid/86:1.5.2015. Home | Discussion: Records should not present erasures, as they make it difficult to plan care. The Slovene Personal Data Protection Act does not specifically govern this area. Even the flow of health records in a medical institution is not defined. The adoption of electronic health records (EHR) and later electronic medical … The legislation does not take social change into account. (ZZdrS-UPB3).72. Objectives Prohibition to Remove Health Records from Hospitals or Clinics. Patients Rights Act (ZPacP): Official Gazette of the Repiblike Slovenia, No. Relevant statutory provisions are the most divergent, the social situation. On the other Yet, much of the data contained in EHRs and EMRs is an unused asset. In the 14th and 15th century, doctor���s records of privacy. Health records are the most important database of health treatment of the patient. | Contact Us. Medical records are important to you for many reasons. Accurate records of observed ch, treatment also attest to the adequacy of the response of health workers. The Slovene Personal Data Protection Act does not specifically are often the best source of information on the state of health and health treatment. Such documentation A qualitative, explorative and descriptive research design was used. Medical auditing, like all audits, is the process of examining and reviewing documents and records to ensure accuracy. 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