Tworzenie i udostępnianie dokumentacji medycznej - proces informatyzacji systemu ochrony zdrowia

It is mandatory, in the light of legal provisions, that all important information should be saved in personal medical documentation of a patient. This procedure is of vital importance, because it not only records the medical treatment of a given patient applied by medical staff, but it also provides a form of mutual informing on the patient’s condition during diagnosis and therapy. The procedure for creating and providing access to medical documentation has not been audited by NIK to date. However, pre-audit examination revealed that the manner in which such documentation is kept does not meet the current standards, and that patients have difficulties with accessing their documentation when they wish to continue treatment at another medical entity, or when they claim that a doctor has made a mistake during therapy.