1. Keeping and storing health and medical records
- Author
-
Pandurov Zora and Jovanović Ružica
- Subjects
medical records ,keeping ,storing ,health workers ,Medicine (General) ,R5-920 - Abstract
The object of the article is to enable health workers/associates and other authorized personnel to acquire new knowledge and skills in following, implementing and linking new regulations with old ones for accurately introducing data into health and medical records, as well as storing those records according to the law. It should be recognized that the Law on Health Documentation and Records in the Field of Healthcare, which is the main subject of this article, declares: "keeping medical documentation and records, writing and sending required reports is a part of the professional medical activity of health institutions, private practice and other legal entities, health workers and health associates". Therefore, the text of the article presents the basic characteristics of all three groups of health documentation and records in health care. The person responsible for the accuracy of recorded data is also designated. This is very important because the medical records are legal documents and they must be complete, accurate and available. Various dilemmas concerning the forms used to collect data have been clarified through examples. It is pointed out that, regardless of the form heading, the data should be entered in accordance to the by-law on Forms and Content of Forms for Keeping Health Documentation, Records, Reports, Registers and Electronic Medical Records. Health workers/associates are acquainted with three ways of keeping records, as well as the conditions for the functioning of IHIS (Integrated Health Information System) in health institutions, but also in private practice and other legal entities. The article ends in quoting legislation on the time and conditions for preserving medical records. We advise the health institutions, private practice and other legal entities to use the year 2020 to prepare themselves, in terms of internal regulations and organization, for 2nd February 2021, which is the date that the Law on Archive Material and Archive Activity will come into effect and which they will need to uphold.
- Published
- 2020