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Anasthesiol Intensivmed Notfallmed Schmerzther · May 2016
[Expert Opinion Cases - What documentation is necessary from a legal perspective?].
- Evelyn Weis.
- Anasthesiol Intensivmed Notfallmed Schmerzther. 2016 May 1; 51 (5): 328-35.
AbstractDoctors are obliged by professional code and civil law (630 f German Civil Code [BGB] §) to document their medical activities in relation to patients. The documentation serves as proof of executed measures and thus for backing up medical/therapeutic issues. Documentation shall be made immediately after or during the treatment and if the original content remains recognizable, can be supplemented/modified. The patient record may be kept in paper form or in electronic form. Medical records are to be stored at least for 10 years. Some special laws (eg. laws governing X rays, Transfusion Act) require that documents be stored for longer periods. Documentation errors are - unlike patient information errors/medical malpractice - no basis for damages claims by the patient, but may result in medical malpractice process with the burden of proof in favor of the patient (§ 630 h BGB). The patient has, in principle, the right to inspect the medical documents relating to him.© Georg Thieme Verlag Stuttgart · New York.
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