When we speak of medical confidentiality, we are referring directly to patient information. This information, shared during consultations, is a diagnostic tool and is stored in the medical record.
The first records of patient disease documents date back to 4,000 B.C., and even ancient Egyptian diagnoses and Hippocratic notes have been discovered, with scientific evidence, of various signs and symptoms. In Brazil, the first institution to integrate the medical archive service was the Hospital of the University of São Paulo, in 1943, and in 1952 the Alípio Correa Netto Law came into force, requiring that public hospitals mainly archive the records.
A medical record must contain various information, among which are: patient identification protocol (equivalent to data such as full name and date of birth), anamnesis, medical evolution, therapeutic plan, reports, and prescriptions, among others.
Although all these records are in the possession of the health professional at their place of care (clinic, office, hospital, etc.), such document belongs to the patient, and the establishment must provide them whenever necessary, as is guaranteed by law that any citizen has the right to access all data about him. Therefore, sharing the medical record or copies of it can only be provided with the patient's authorization.
Even if the patient's medical record is, by law, hospitals are responsible for preserving any documents regarding diseases, treatments, and exams. The objective is to ensure that this information is available whenever requested.
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Concerning such information, let's see what the Brazilian Code of Medical Ethics says in some of its articles on medical confidentiality:
"Art. 73 - It is forbidden for the doctor to reveal the fact that he has knowledge due to the exercise of his profession, except for a just reason, legal duty or written consent of the patient. ”
"Art. 85 - It is forbidden for the doctor to allow the handling and knowledge of medical records by people who are not bound by professional secrecy, when under their responsibility. ”
Also, to help maintain confidentiality, we have Law No. 2,848 of the Brazilian Penal Code, where the article on violation of professional secrecy says that:
"Art. 154 - To reveal someone, without just cause, secret, that they have knowledge due to function, ministry, office, or profession, and whose disclosure may harm others: Penalty - imprisonment, from three months to one year, or fine."
Something important to note is that all medical records must be kept in Brazil by the institution for at least 20 years. This means that during all this time, such documents will occupy significant physical space.
In addition to the space occupied, there is also a concern with possible accidents that may result in the total loss of this material, as in the case of fire, for example. And last but not least, there is a risk of someone unauthorized having access to these documents, which can even culminate in legal proceedings.
For these and so many other reasons, the use of medical software is so important. With good software, medical records are safer, there is no need to complete them, in addition to taking up less physical space and making the documentation of care more practical.
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