Medical records in electronic form. Problems with implementing a duty

Zakład Prawa Medycznego, Uniwersytet Medyczny w Łodzi. Kierownik Zakładu: prof. dr hab. Rafał Kubiak
Adres do korespondencji: Dr n. prawn. Jakub Rzymowski, ul. Jadwigi 32, 92-107 Łódź, e-mail: rzym@prawokomputerowe.pl
Praca finansowana ze środków własnych

Pediatr Med rodz Vol 10 Numer 1, p. 85–90
DOI: 10.15557/PiMR.2014.0013
ABSTRACT

The article is devoted to implementation of a duty of maintaining electronic medical records. The date of the duty’s commencement is not known but the very coming into existence of the duty is quite possible. The duty of maintaining electronic medical records means that every medical documentation, namely either the collective or individual medical documentation, made and kept in electronic version – computer files. The significant problem is a phenomenon of paper documents annexed to electronic documentation. One can also find in the text some considerations about admissibility of writing electronic documentation on paper after the entry into force of a duty of maintaining electronic medical records. The premises of admissibility of maintaining electronic medical records have been analysed as well.

Keywords: medical records in electronic version, medical records, medical records in paper version, archiving of records, ICT system (Information and Communication Technologies)