PROBLEMS RELATED TO MEDICAL DOCUMENTATION IN MEDICAL STRUCTURES (4-8)

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Дата публикации статьи в журнале: 2020/05/12
Название журнала: Восточно Европейский Научный Журнал, Выпуск: 56, Том: 1, Страницы в выпуске: 4-8
Автор: Svetlana Radeva
Varna , Specialized hospital of obstetrics and gynegology for active treatment „Prof. D. Stamatov”, ,
Анотация: Medical documentation tracks the patient's path during the diagnostic and treatment process and recreates in writing all the services rendered, therapeutic and diagnostic procedures. A visual representation of the data allows you to track changes in the patient's condition and therapeutic response to treatment. It is essential that everything is documented and supported by materials (research, protocols, photos, dependencies, records, etc.). Primary medical documents are subject to regulatory requirements. Proper replenishment guarantees adequate treatment and care. Creating documents with different content leads to moral and legal consequences, which also affect the adequacy of the treatment and the desired effect. The General law regulating the collection and processing of medical information for citizens is the Health law. According to him, health information is personal data related to the state of health, physical and mental development of people, as well as any other information contained in medical prescriptions, prescriptions, protocols, certificates and other medical documentation. The preparation of individual medical documents is regulated by the National framework agreement on medical activities for medical care contractors(hospital and outpatient). According To the law on the protection of personal data information from the medical records of individuals is protected personal data. The Health law defines the circle of persons who have the right to process personal data of citizens related to their health status. These are medical and medical institutions, competent state authorities in the field of health and medical insurance, as well as relevant medical specialists. The processing, use and storage of unidentified details of the individual medical data and the exchange of medical and statistical information is carried out in accordance with the regulations of the Minister of health, agreed with the National statistical Institute.
Ключевые слова: medical data   documents   hospital   regulations   responsibilities  
Данные для цитирования: Svetlana Radeva , . PROBLEMS RELATED TO MEDICAL DOCUMENTATION IN MEDICAL STRUCTURES (4-8). Восточно Европейский Научный Журнал. Медицинские науки. 2020/05/12; 56(1):4-8.

Список литературы: 1. Code of professional ethics for doctors in Bulgaria (caps. ISM. - DV, br. 85 since 2013.) 2. Code of professional ethics for nurses, midwives and associated medical professionals. State newspaper br.45 since June 19, 2015. 3. Health law, ed., equation. 101 from 27.12.2019 4. National framework agreement on medical activities 2020-2022. 5. Radeva M. For some legal aspects of medical documentation. Rusen University, faculty of law. Notifications of the Union of scientists-Varna 1 ' 2014 / Tom XIX. 6. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of individuals in connection with the processing of personal data and the free movement of such data and the repeal of Directive 95/46 / EC (General data protection regulation) 7. Resolution on granting the right to access medical care. Published by the state newspaper. equation.45 since June 2, 2006. last amendment state newspaper article 29 of April 7, 2017.