Health Documentation in the Age of Information Systems

Theoretical background: Health documentation is historically gained such an important legal document for the exercise of individual rights becomes increasingly important role. Domestic legislation but health records as legally significant collection of medical data and documents are not defined. Retention of important legal documents, therefore, it left to the operator. Methods: Using the prescriptive method will be determined and the laws governing the management of health documentation, safety and accessibility of health care documents. Based on descriptive methods will be described handling of health records within a provider of health treatment to exposed regulatory gaps in the protection of individual rights. Results: Through the analysis of the behavior of operators with health records, even after death, leaving the contractor will be the inductive reasoning carried out conclusions on the management of health records. Discussion and conclusions: Health data, in particular documents, which are to protect the individual rights relevant health records are not processed in modern technology. Health records are still kept manually, records of the documents in the collection are not allowing their disposal. Even the flow of health records in a medical institution is not defined. Manual and thus not trasparent data processing treatment consequently forms the basis for alienation of individual records or entire medical documentation and access by unauthorized persons. Due to the diversification of health data within a single controller comes to redundancy investigations, which increases costs and unnecessary divergence of time adequate medical treatment