Anamnesis, diagnosis, course of treatment – these are basic contents of a medical documentation.
The doctor’s duty of documentation is a secondary obligation arising from the Treatment contract. A patient’s personal rights are protected in the constitution, which means that he or she has the right to know what is happening to his or her body. A patient is entitled to proper documentation and the right to see it. In particular, the doctor enables unconscious accident victims or anaesthetised patients to obtain information when they wake up.
In addition to the findings, the treating physician should also document therapeutic measures that have been initiated and questions that need to be clarified. The careful storage of further documents such as X-rays, ultrasound, laboratory results, ECG strips, operation reports includes this documentation obligation. Facts such as the patient’s behaviour which influences the healing process or possible allergies are also included.
The aim of documentation is to make the course of treatment visible. If the doctor treats the patient over a longer period of time, he can look at the documentation himself. But also other doctors such as successors, representatives or continuing doctors can follow the treatment and thus continue it more easily. For example, the treatment should not be prolonged unnecessarily by repeating measures already carried out.
The doctor must be accountable to his patient and to cost units such as the health insurance company. The patient can obtain a medical second opinion on the basis of the documentation or can make himself/herself understood within the framework of his/her personal rights.
Furthermore, the medical documentation serves as evidence in court. It can show whether the treatment was justified and whether the doctor declared has
The legislator sets the following conditions for the documentation: it should be timely, complete and consistent. In a possible lawsuit, these characteristics are particularly important; if the documentation fulfils the conditions, it is legally binding as evidence for the patient and the doctor. As a rule, the patient must prove a mistake made by the doctor. Insufficient documentation is invalid, which is at the expense of the doctor. The court assumes the worst case scenario to the detriment of the doctor and the doctor must prove that he has acted correctly. This is called reversal of the burden of proof.
The documentation has three objectives: Therapy, accountability and preservation of evidence. As a rule of thumb, the more complicated a treatment is, the more accurately it should be documented.
The security of the electronic data of a documentation is particularly important in this case. Sufficient protection must be guaranteed from unlawful use, premature destruction and subsequent modification.
According to the basic data protection regulation, the patient’s consent is required for the storage of his/her data.