[Electronic medical records: medical and legal aspects, privacy, safety, and legal validity].
Medical records must collect all data concerning in-hospital management of patients: data have to be verified and easily retrievable. Clinicians are responsible for both format and content of medical records. Respect of patient's privacy must be made sure both during on-line management and long-term storage of records. Computerization can offer many advantages to clinicians, but needs some significant adjustments: training and motivation of operators, arrangement of clinical processes and of administrative rules to technological developments. Nevertheless, some important results can be afforded: standardization of procedures, distribution of univocal, verified and ubiquitous data to all concerned operators, protection against undesired retrieval, reliability of effective reports. Preliminary condition is a clinical local area network, widespread into the institution. Database implementation must follow well accepted methodology: flow chart design of data dictionary, standardization of data coding, input of verified data, effective reporting. Access to data must be controlled by sophisticated and sure password system. Back-up of data must be automatically available with adequate timing and methodology. Respect of rules on patient's privacy must be realized whenever possible. Complex clinical records should be made available, containing data, signals and images (both single frames and dynamic sequences), due to continuous technical progress of diagnostic tools. Medical records must be available for long periods of time: database engine and managing tools must be selected among well accepted and largely available producers; informatic assistance must be assured for management and evolution of systems over the years.
Ravizza
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Dipartimento di Cardiologia, Ospedale A. Manzoni, Lecco. pfrav@tiscalinet.it
Pasini
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E
D003201:Computers; D003219:Confidentiality; D006801:Humans; D007558:Italy; D016347:Medical Records Systems, Computerized / Q000331:legislation & jurisprudence*; D012984:Software