The legal discipline of medical record <b>[Abstract in English]</b>

Abstract

Questions surrounding the issue of medical records are always of great interest and importance. It is in this spirit that Scientia Medica is publishing an article on electronic patient record, a reality that, sooner or later, all institutions providing health care will have to adapt. It is true that many difficulties must be overcome before implementing, with absolute safety, the records in electronic media. Among other issues to be addressed are the legal issues. It is essential for medical and law professionals knowing the legal guidelines on the subject, allowing the construction of valid medical documents, both in electronic or traditional media, for patient care and also as a means of defense. The Federal Council of Medicine has been supplying various legislative absences with their resolutions. However, formal legislation on some issues relating to medical records, including those related to digital or computerized records, would confer the necessary legal safety for this process to walk much more advanced.