Medical Document Filing Procedure

Original Language Title: Medicīnisko dokumentu lietvedības kārtība

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Cabinet of Ministers Regulations No. 265 in 2006 (April 4. No 19 37) medical treatment institutions and accounting record keeping procedures of documentation Issued in accordance with article 59 of the law on the treatment of i. General questions 1. determines the medical treatment institutions and accounting records of the documentation (hereinafter referred to as the record keeping procedures).
2. Filing procedure is binding on all the authorities of the Republic of Latvia for treatment.
3. Filing procedure is a medical authority raised the minimum requirements, which the health statistics and medical technologies State Agency (hereinafter Agency) take into account in the conformity assessment of the medical establishment.
4. This rule controls the medical care and integrity inspection quality control inspection.
II. medical records and documentation of accounting 5. Medical and accounting documentation on primary health care, secondary health care and emergency medical assistance (medical records) creates a single piece of information. Medical records collects and stores the family physician (internist of primary health care, primary health care pediatrician).
6. If the patient changes the family doctor (internist primary health care, primary health care, Pediatrics), family doctor puts the patient's designated family physician complete medical records of the patient.
7. the Outpatient in the Hospital of the medical records of patients account for a patient's outpatient card. The fixed medical institution the medical records of the patient constitutes the patient's medical history.
8. Information on patient health care services provided, received another medical institution or provided by the other party, the treatment your treating doctor will add patient medical records.
9. From the hospital's inpatient discharges the patient medical records completed and shall be deposited in the hospital hospital's register no later than 14 days after discharge from the Hospital Authority for treatment. About medical record storage in the transfer of hospital treatment in the Hospital Authority's filing answer treatment services manager in charge of treatment designated person.
III. the content of the medical record and protection 10. Medical records contain information that the patient provides visibility, confirms the diagnosis, based studies and accurately reflects the results of treatment.
11. Medical records that is fillable hospital medical institution, also fill in outpatient institutions, if the relevant authorities of the hospital's outpatient day surgery, the patient is made to the section surgical operation or manipulation.
12. Medical records, disease progress recordable 24 hours after reception of the fixed medical institution.
13. If you have obtained or submitted additional information on any activity that is related to the patient's treatment, manipulation and the preoperative period, it immediately adds the medical records.
14. Opinion on the completion of hospitalization can be replaced in the final entry, which contains information on treatment outcomes and recommendations if: 14.1. the patient requires hospitalization for a period of less than 48 hours;
14.2. birth born healthy baby and childbirth without complications proceeded.
15. If the intervening death of patient medical records added to the opinion on the death and final record indicates the purpose for which the patient is admitted to the Hospital (if the patient died in the hospital), examination results and a course of treatment, as well as the causes of death.
16. If, after the patient's death, the autopsy, pathological diagnosis adds medical records within three days, but the complete medical records of the add 30 days after the autopsy.
17. one of the hospital's outpatient medical record is a collection of components. The summary contains the following information: 17.1. diagnosis;
17.2. the particulars of the above pārciestaj diseases (including infectious diseases) and injuries (by patient name);
17.3. the known essential surgical and invasive procedures;
17.4. known adverse allergic reactions and;
17.5. the message about drugs that are regularly used.
18. the series is in the patient's outpatient card in the same place. It fills the first illness and chronic illness aggravated in the case of a patient for the first time visiting a medical person. A summary of treatment of the person below, supplemented by patient visits you. If the important information about the patient is also yet another medical record, is written in the reference collection, which can be found in the relevant information. Diagnosis or assessment of the situation is required to specify again the same treatment.
19. With the news that the medical records of patients included and are stored in the medical institution, he can be found by visiting the treating doctor medical institution. Treating physician's responsibility to provide a meaningful way to the patient medical records included information about the patient's diagnosis, examination and treatment plan for other treatment methods and disease forecast, as well as explain the medical record entries in the content.
20. The patient shall have the right to medical treatment of the person or authority in the presence of the employee type a note in medical records, then dedicated space, if he considers that the information in the records is incorrect or inaccurate.
21. If the treating doctor or the hospital's Manager has determined that medical record content information which is specially protected, it kept separate to the technical media. In this case, medical records showing the relevant part of the location information.
22. the head of the hospital's medical records and ensure that they contain protection against deletion of the information, the fact of the alteration and unauthorised use and designated as medical records and the protection of the information contained therein the responsible medical person (hereinafter person responsible).
23. the medical treatment of a person involved in the hospital's work ensures that patient medical records and the information they contain could not access the treatment not involved in the process.
24. Outside the hospital's working time patient medical records and the information they contain in a separate lockable room or cabinets, lockers to ensure treatment processes involved in accessing. Rooms or lockers for keys stored in a responsible person.
IV. the medical record quality 25. medical records is truly, fully, legibly and without amendments.
26. records medical record can only be performed on the person for treatment. Electronically prepare reports on the examination conducted to the patient signs the treating doctor and accompanied by medical records.
27. the referring physician to certify compliance of patient health care, treatment of persons in obvious facts indicate the medical records. Records that medical record of treatment carried out, as the doctor, establishes the hospital's internal rules. Symbols and abbreviations may be used only in cases provided for in the hospital's internal rules.
28. Patomorfoloģisk messages, as well as a description of the operation and epikrīz are printed.
29. The medical record is completely finished, if it contains all of these rules require certain ingredients, including epikrīz or closing record, and if it is recorded in all the final diagnosis and complications.
30. If medical records reasonably necessary repairs, to provide medical records in the preservation of the original keep information and add them.
V. medical facilities use medical records documentation and forms and their storage time limits 31. Hospital treatment services uses the form referred to in that rule 1., 2., 3., 4., 5., 6., 7., 8., 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38. , 39, 40, 41, 42, 43, 44, 83 and 85 of the annex.
32. Outpatient institutions use the form referred to in that rule 27, 45, 46, 47, 49, 50, 51, 52, 53, 55, 56, 57, 58, 60, 61, 85, and 86, as well as in annex 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 30, 31, 32, 33, 39, 40, 41, 42, 43, 44 and 84. Annex.
33. Treatment services, which are not mentioned in this provision in paragraph 31 and 32, use the form referred to in that rule 62, 63, 64, 65, 66, 67 and 68 in the annex.
34. Treatment services using standard medical form, referred to in this rule 48, 54, 59, 69, 70, 71, 72, 73, 74, 75, 76, 78, 77, 79, 80, 81 and 82. Annex.

35. Medical records indicated: this provision 5 21.8., 10, 15, 17, 18, 24, 28, 29, 39, 40, 41, 53, 55, 56, 63, 65, 75, 83, and 86. the forms referred to in the annex, shall be kept for one year after the last record;
35.2. This provision 8, 25, 36 and 37 the forms listed in the annex, shall be kept for two years after the last record;
35.3. this rule 26, 33, 52, 62 and 85 forms listed in the annex, shall be kept for three years after the last record;
35.4. the rules 4, 7, 9, 11, 23, 31, 32, 38, 42, 45, 46, 50, 51, 58, 60, 66, 67, 68, 69, 79, 80, 81 and 82. Annex, shall keep for a period of five years following the last record;
22.1. this rule 6, 16, 27 and 57. the forms referred to in the annex, for 10 years after the last record;
22.1. these rules 43 and 44. the forms referred to in the annex, shall be kept 15 years after the last entry;
22.2.61. these provisions contained in the annex to the form stored in the 25 years after the last entry;
22.2. that rule 1, 2, 3, 13, 14, 19, 20, 21, 22, 30, 34, 35, 47, 48, 49, 59, 64, 70, 71, 72, 73, 74, 76, 78 and 84 77,. Annex, shall keep 75 years after the last record;
22.3.64. these provisions referred to in annex pavadlap in the form of vouchers, stores one year.
Vi. Closing questions 36. This provision 19, 31, 32, 33 and 34 shall enter into force by 1 July 2006.
37. This provision, paragraph 20 and 24 come into force by 1 January 2007.
Prime Minister a. Halloween Health Minister g. Smith Editorial Note: the entry into force of the provisions to the 8 April 2006.
Annex 1-86 ZIP 1.1 mb