Electronic medical documentation – selected legal aspects

Abstract

The purpose of this article is to discuss selected legal issues related to the keeping, access and sharing of medical records. Attention is paid to a specific form of medical records, namely electronic medical records (EDR). The legal basis and its dynamic changes regarding the introduction of electronic medical records to hospitals and other medical facilities were indicated. The issues of basic differences between traditional medical records and their electronic counterparts, the distinction between electronic medical records and electronic medical records, cases and conditions for preparing documentation in both forms, and specific documents should be prepared in an electronic version for specific reasons. There are also indicated entities with access and appropriate authorizations to electronic medical records. Attention is also paid on the meaning and form of the signature. At the end, the conclusions resulting from the implementation and use of electronic medical documentation are presented.