Responsibility and conservation of clinical documentation in Asturias
Introduction
The medical history is the set of documents that comprise the valuations, data and information about the State and the clinical evolution of a patient throughout the care process. It can be prepared in paper support, audiovisual, computer or any other, as long as all changes are guaranteed as well as those who do it and when. It contains all the information that is considered essential for the true and updated knowledge of the patient’s situation and the identification of professionals who have intervened in assistance. It fulfills important functions such as the jurisdictional, that of research, teaching or inspection, evaluation, accreditation and planning.
Objectives
Monitoring director committee, find out who is responsible for the clinical documentation, who handles the documentation and how, where and how much time it is preserved.
Methodology
- Law 3/2005, of July 8, on health information and patient autonomy.
- Law 41/2002, of November 14, Basic Regulatory of the Patient Autonomy and of Rights and Obligations on Information and Clinical Documentation.
- Decree 51/2019, of June 21, which regulates the medical history and other clinical documentation. Bopa
- Administrative operations and health documentation. Novelty 2017. Written by Gloria Sánchez Casado, Gonzalo J. Mingo
- Decree 21/1996, of June 6, which regulates the organization and operation of the administrative archive system of the Principality of Asturias.
Results
The Director of Monitoring Committee for the Clinical History of the Principality of Asturias depends on the General Directorate. Its functions consist of the coordination of the medical history and documentation commissions of the health areas;the normalization of the structure and order of documents and records in the medical history, as well as the personnel in charge of its realization;the definition of criteria on access, expurg and destruction of stories, actions in case of loss and on the special custody of certain medical records;the evaluation of all those requests for change or evolution in their contents and structure.
Decree 51/2019, of June 21, which regulates the medical history and other clinical documentation also regulates how it should be and how another clinical documentation is managed, such as the high, urgent report or medical certificates and the medical certificates andAnother documentation related to patient health.
Special custody modules, in paper and electronics history, the aforementioned decree will establish specific mechanisms. Content correspond to the areas of genetics, sexuality, reproduction, mental health, organ transplantation, infectious diseases, prevention of occupational hazards and data related to domestic violence.
The person responsible for managing and guarding the clinical documentation falls on the direction of health centers and services. These will set the necessary measures to ensure:
- The right to privacy of patients and the secret duty of anyone who has access to information containing the medical history or any clinical documentation.
- Creation of technical and organizational security measures in accordance with current legislation on personal data protection.
- Rights of access, rectification, suppression, limitation of treatment, portability and opposition according to current legislation on personal data protection.
- Clinical documentation will be available by authorized personnel accessing it for justified purposes.
In Asturias, in Sespa, who adopts these measures and has the responsibility of them is their management management.
There is a patient file for the location of the medical records and that is very important since it allows us to control where the documentation is at all times, in the file, have been provided or recorded once the professional has accessed it. This file contains identifying data that belong to the patient, which are their personal data, as well as the updated location of the story, if it is in the file or if it has been provided, in which case the reason for the request, the service or thePerson who has it in custody, the date on which it has been provided, the return, etc., being all in computer support. The identification of the medical history will be done through the Autonomic Personal Identification Code, to which the medical history numbers that may exist in health centers and services will be linked.
In Asturias we find the Millenium program (in Huca, Oviedo) and Selene (in the rest of the region).
Archive management is responsible for the service or clinical admission and documentation unit, which will exist in those centers that have hospitalized patients or attend to a sufficient number of patients under any other care modality. This service or unit will be responsible for integrating into the unique file, the different documents that form the medical history, such as the data that allow its subsequent recovery. When these services do not exist, the management will correspond to who determines the center’s address.
The Clinical Administration and Documentation Service is a service composed of health and non -health professionals, with the dependency of the person responsible for the SADC that should be a doctor with training in this discipline, integrating the contacts and care movements of the patients of that hospital. This management must be done in a coordinated manner with the objective of activating the resources, personnel and spaces necessary to correctly serve each patient.
Information systems must guarantee quality, accessibility, interoperability, technical security and the integration of all the clinical care information to favor coordination and healthcare continuity.
Health professionals who develop their activity in the private sphere, provided they do so through their own personal and material means, are responsible for the management and custody of the medical records or any other clinical documentation that generate. Otherwise, the responsibility will be from the center where they develop their activity.
The change in clinical information from the original support to another support, it should be guaranteed that it does not vary, that it is authentic and that it is permanent of the care information, as well as the privacy of the data and the information that it includes.
Each health center will order the care content in the establishments that ensure the protection and confidentiality of the personal data contained in them, their adequate preservation and recovery of the information and it must also be appropriate to the volume of stored documentation and the demand for the demand for the demand for the demand foractivity received, this being possible by specialized personnel.
An authentic electronic copy of the clinical documentation can be obtained in accordance with the requirements of article 27 of Law 39/2015 of October 1, in order to protect its authenticity, security, integrity and future reproduction. Once the copy is obtained, clinical documentation can be destroyed in its original support through methods that ensure your complete elimination.
The clinical documentation must be preserved at least five years from the date of the discharge of each care process or from the death of the patient, with the exceptions indicated by the law. This file is called "Active Archive". After these years, it will go to a “passive archive”, where you can destroy documents that are not considered transcendental for assistance, public health, epidemiological, research, judicial or reasons for reasons of organization and operation of the National Health System of the National Health System. Your treatment will be done so that the identification of affected people is avoided as much as possible.
The clinical documentation of the services of nuclear and radiotherapy medicine will be retained during the thirty -year period that is expected in Royal Decree 1841/1997, of December 5, which establishes the quality criteria in nuclear medicine, and inRoyal Decree 1566/1998, of July 17, which establishes the quality criteria in radiotherapy. The clinical documentation that is documentary test in a judicial process cannot be destroyed.
They will be indefinite conservation documents, although not necessarily in the original support:
- Complementary explorations reports
- The informed consent document
- The operating room or childbirth registration report
- The document on the newborn of its medical history
- The anesthesia report
- High clinical reports
- The high volunteer document
- Pathological anatomy and necropsy reports
- The implantation cards corresponding to the implants made
- Other documents that are not cited in this section but that are necessary for the reasons provided for in article 39.1
The data of the medical history related to the birth of the patient, including the results of the biometric, medical or analytical tests that are necessary to determine the bond of affiliation with the mother, will not be destroyed, moving, once thedeath of the patient, to the central archive that corresponds to the provisions of Decree 21/1996, of June 6, which regulates the organization and operation of the administrative archives of the Principality of Asturias, where they will be kept with thedue security measures for the purposes of current legislation on personal data protection.
The central archives in the different councils, agencies or entities, will guard the semi -active documentation of frequent use of the corresponding producing offices and operate following the technical guidelines of the General Archive. This will act as the head of the system and will be the one that will establish the technical and operational standards of all files including those of the Administration of the Principality of Asturias. It will work as a central file in relation to semi -active documentation deposits of frequent use and as an intermediate file in relation to all semi -active sporadic use documentation.
The documentation that has been deposited in the Central Archive will go to the General Archive after fifteen years of its entry into the same. It could be sent before these years if the use of these documents is sporadic at the proposal of the Central Archive with approval of the General Technical Secretariat of the corresponding Ministry.
The General Archive may transfer to the Historical Archive of Asturias all the inactive documentation that has lost its administrative utility and retains permanent or historical value. The transfer will be ordered by resolution of the Minister of Cooperation, prior report of the head of the General Archive of the Administration of the Principality of Asturias.
conclusion
The Committee Director of Monitoring of the medical records in Asturias will depend on the General Directorate. Normalizes the structure and order of documents and records, defines accesses, expurg and destruction of stories, about loss, special custody among other functions. It is responsible for managing and guarding the clinical documentation is the direction of the health centers and services that will take the necessary measures for the protection of data and the right of the intimacy of the patient among others. In the case of Asturias the responsibility will be from the Management Directorate. The archive management will take charge of the SADC clinical admission and documentation service, composed of health and non -sanitary personnel. Will incorporate into the unique file, the different documents that form the medical history, such as the data that allow its subsequent recovery. The documentation will be preserved at least five years, after this they will be passed to a passive file, where documents that are not considered transcendental can be destroyed. Some documents will have an indefinite conservation but should not necessarily be on original support. The central files will be those that guard the semi -active documentation of frequent use and as an intermediate file with the semi -active documentation for sporadic use. After fifteen years or before if it is considered appropriate, it refers to the General Archive. The latter will transfer it to the historical archive all inactive documentation but has permanent and historical value.
Leave feedback