title: [Expert Opinion Cases - What documentation is necessary from a legal perspective?].
abstract: Doctors are obliged by professional code and civil law (630 f German Civil Code [BGB] §) to document their medical activities in relation to patients. The documentation serves as proof of executed measures and thus for backing up medical/therapeutic issues. Documentation shall be made immediately after or during the treatment and if the original content remains recognizable, can be supplemented/modified. The patient record may be kept in paper form or in electronic form. Medical records are to be stored at least for 10 years. Some special laws (eg. laws governing X rays, Transfusion Act) require that documents be stored for longer periods. Documentation errors are - unlike patient information errors/medical malpractice - no basis for damages claims by the patient, but may result in medical malpractice process with the burden of proof in favor of the patient (§ 630 h BGB). The patient has, in principle, the right to inspect the medical documents relating to him.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Weis
mesh_terms: D000758:Anesthesia / Q000009:adverse effects*; D000776:Anesthesiology / Q000331:legislation & jurisprudence*; D004282:Documentation / Q000592:standards*; D005858:Germany; D006801:Humans; D016365:Liability, Legal; D008318:Malpractice; D019300:Medical Errors / Q000331:legislation & jurisprudence*