Aspectos médicos legales de la historia clínica / Medical legal aspects of medical history

La historia clínica es un documento de prueba de lo transcurrido durante la prestación asistencial. No se trata de un mero hecho administrativo, sino de un acto médico destinado, desde el punto de vista procesal, a dejar constancia del cumplimiento de las obligaciones que le corresponden al profesional y al paciente. La jurisprudencia de nuestro país destaca tal importancia a través de fallos históricos

La protección de datos en la práctica privada / Data protection in private practice

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A pain in the back case.

I This article discusses a Supreme Court case involving a patient who was referred to a chiropractor for treatment of neck pain. The case highlights some important issues, including the: importance of good medical record keeping, duty to read patient documentation, including previous medical records, duty to perform a physical examination, and duty to consider if a referral is appropriate

Conforming to HIPAA regulations and compilation of research data.

PURPOSE: A set of deidentified patient data compliant with the Health Information Portability and Accountability Act (HIPAA) was compiled, the data lost as a function of unique data elements (UDEs) were measured, and the deidentified data were tested for potential for reidentification. METHODS: After approval by the institutional review board of an integrated health system, a limited-data set was created by querying the health system's pharmacy, administrative, and financial files for patients discharged between January 1 and December 31, 2000. Using the HIPAA "safe-harbor" method, this limited-data set was converted into a deidentified-data table for future statistical analysis, and UDEs in both data sets were identified and quantified. Unique combinations of commonly available data were also identified. RESULTS: The limited-data set, representing 4,738 patient discharges, contained 810,456 UDEs in 322,657 records organized into four data tables (demographics, diagnoses, medication orders, and laboratory test results). The deidentified-data table, representing 4,722 discharges, contained 562,171 UDEs in 128 data-type columns in a single data table. About 31% of the data volume was lost. Much of the information lost was of the type that is of special interest to researchers (e.g., time between episodes of care, ages of >89 years). CONCLUSION: A study suggested that deidentified patient data with a reasonable degree of protection against reidentification were less complete than may be necessary for good research.

[New dermatologist's procedure. Research plans for improving secondary prevention of occupational dermatoses]. / Das neue Hautarztverfahren. Forschungsvorhaben zur Verbesserung der Sekundärprävention von Berufsdermatosen.

The dermatologist's procedure was introduced in 1972 by employers' liability insurance funds in the industrial, agricultural, and public sectors of Germany's statutory occupational accident insurance as a "procedure for early detection of occupational skin diseases." So far, it is still the most relevant tool for secondary prevention in occupational dermatology in Germany. According to the intention of this procedure, insured persons with a skin disease in which an occupational etiology is suspected must be offered preventive measures and, if necessary, given appropriate treatment to avoid job-loss. To improve the efficiency of the "classic" dermatologist's procedure, in 1999, on the initiative of the Central Federation of Industrial Professional Associations, a study group was founded in cooperation with the Task Force on Occupational and Environmental Dermatology of the German Dermatological Society and the Professional Organisation of German Dermatologists. In October 2002, a controlled intervention study started in North-western Germany to scientifically evaluate the "optimised" dermatologist's procedure, which was proposed by the study group and compare it to the standard ("classic") procedure. The study results should allow detailed suggestions for an improved dermatologist's procedure before it is introduced nationwide.

Cuestiones relativas a la historia clínica

El presente articulo tiene por objeto establecer los documentos que constituyen el registro de actividades clínicas y se dirige a establecer los contenidos mínimos que deben de constar en la historia clínica, así como a establecer un modelo de la misma orientado al ámbito de las Ciencias Podológicas. (AU)