a 2014

Medical documentation and its importance in today's medicine - Survey in surgical wards.

SCHWANHAEUSER WULFF, Kräuff Rainer a Jana HUDCOVSKÁ

Základní údaje

Originální název

Medical documentation and its importance in today's medicine - Survey in surgical wards.

Autoři

Vydání

XIV. Celostátní konference s mezinárodní účastí - Slezské dny preventivní medicíny, 2014

Další údaje

Jazyk

angličtina

Typ výsledku

Konferenční abstrakt

Obor

30300 3.3 Health sciences

Stát vydavatele

Česká republika

Utajení

není předmětem státního či obchodního tajemství

Označené pro přenos do RIV

Ano

Kód RIV

RIV/00216224:14110/14:00091774

Organizační jednotka

Lékařská fakulta

ISBN

978-80-260-5923-3

Klíčová slova anglicky

Medical docummentation; surgical wards; audit; England; Czech Republic.

Příznaky

Recenzováno

Anotace

V originále

Aim Emphasize the importance of medical documentation. Introduction The medical documentation is not just to keep information on each patient, noting their progress on a daily basis, but in a society where the number of demands is increasing, it can be a double-edge knife, if not filled properly. It is also a medico-legal tool, which will help to avoid any complication in future. In addition, medical documentation serves as an educational tool for medical students, residents and qualified doctors. As it records sensitive information, it must be handled and stored in an appropriate way (many ethical and legal issues are implicated). It is of great importance to bear on mind that medical documentation is a legal document, so it can be used as evidence. Discussion It is recommended to carry out frequent internal audits in order to ensure quality in the documentation and to encourage staff to work with it in the best manner. Medical documentation must be kept in a complete and clear way in order to avoid medico-legal complications in future.