I see on Facebook Alejandro Abraham’s initiative for the country to adopt the Digital Clinical History, and I have already adhered. Law 26.529 that regulates the rights of the patient, in terms of the autonomy of the will, the information and the clinical documentation, specifies certain guidelines that a clinical history must meet. Among these guidelines, there is the confidentiality of information between the doctor and the patient, and any health professional who may have access to it. Article 14 specifies that the patient is the owner of the clinical history and that at its simple request a copy of it must be provided. But in turn, article 17, indicates the uniqueness of the clinical records by establishment. That is, each health facility must have a particular clinical history, completely isolated from any other institution.
Relevant in Law 26,529, articles 2 (sections C and D), article 13, article 14, article 17 and article 18 are relevant. I believe that all health professionals waste a lot of time and effort trying to understand the handwriting of colleagues in all types of clinical documents, which causes delays and sometimes serious errors.
The forums of biochemists and pharmacists are full of queries about what the doctor meant in this or that a doodle. And as it remains mandatory that prescriptions be MANUSCRIPTS, the responsible is the same State and its adherence to archaic legislation. Added Nov.2018 : the new legislation on electronic signature says that this modality can replace previous methods of signature, which authorizes to sign recipes digitally. But the body of the recipe is still subject to the letter of the law, which requires it to be handwritten. By not repealing or changing the Law of Exercise of Medicine, the issue remains confused and subject to controversy.
