title: [Patient autonomy and information and clinical documentation-related rights within the context of Spanish Law 41/2002].
abstract: Law 41/2002 Regulating Patient Autonomy and Health Documentation and Information-Related Rights and Obligations regulates matters which the General Health Law of 1986 had fallen short in its attempt to regulate, such as the right to health information, informed consent, health documentation, clinical records and other clinical information. This Law likewise classifies the ways in which capabilities may be limited and attributes physicians with authority over the evaluation thereof. In keeping with the Oviedo Convention on Human Rights and Biomedicine, this study includes the guiding principles of the new bioethics, such as an individual's right to privacy of the health-related information, living wills (or advance medical directives), the patient's right to antonomy and to take part in the decision-making process, the refusal of treatment or teenagers being of legal age for health-related decision-making purposes. Said Law, a primary law nation-wide, means a major advancement in physician-patient relations and must be further expanded upon with regard to numerous aspects thereof by the Autonomous Communities. This study is aimed at describing this body of law and at analysing the repercussions thereof on citizen relations, health professionals and the National Health System as regards the matter of clinical documentation and information.
authors.affiliation: Servicio de Admisión y Documentación Clínica, Hospital Punta de Europa, Algeciras, Cádiz. cesareo.garcia.sspa@juntadeandalucia.es
authors.forename: Cesáreo
authors.initials: C
authors.lastname: García Ortega
authors.forename: Victoria
authors.initials: V
authors.lastname: Cózar Murillo
authors.forename: José
authors.initials: J
authors.lastname: Almenara Barrios
mesh_terms: D003219:Confidentiality; D004992:Ethics, Medical; D006801:Humans; D007258:Informed Consent; D008499:Medical Records / Q000331:legislation & jurisprudence* / Q000592:standards; D028701:Patient Rights / Q000331:legislation & jurisprudence*; D026684:Personal Autonomy; D013030:Spain
vernacular_title: La autonomía del paciente y los derechos en materia de información y documentación clínica en el contexto de la Ley 41/2002.