Medical record documentation – a file of documents which 
     carry any medical information about a patient/patients 
        Who owns the medical record documentation?
        ENTITY PROVIDING MEDICAL SERVICES
             Who own the information?
             ENTITY PROVIDING MEDICAL SERVICES (CAN NOT 
             FREELY DISPOSE THE INFORMATION)
                  What about the patient?         
                  HE HAS THE RIGHT TO GET FULL INFORMATION
          •   Act of 5 December 1996 on Professions of Doctor and Dentist
          •   The Code of Medical Ethics
          •   Act of 29 August 1997 on the Protection of Personal Data
                                                                                        Ordinance of the 
                                                                                        Ordinance of the 
                                                                                        Minister of Health 
                                                                                        Minister of Health 
                                                                                         of 21 December 
                                                                                         of 21 December 
                  Act of 6 November 2008 on                                            2010 on the types, 
                                                                                       2010 on the types, 
                Patient Rights and the Patient                                               scope and 
                                                                                             scope and 
                      Rights Ombudsman                                                     templates of 
                                                                                           templates of 
                                                                                         medical records 
                                                                                         medical records 
                                                                                         and methods of 
                                                                                         and methods of 
                                                                                         their processing
                                                                                         their processing
     • Patient right to get medical record documentation about 
      his/her health condition and provided medical services
     • Entity providing medical services obligations: running, storing, 
      proper sharing (following the Act of 6 November 2008 on Patient Rights and 
      the Patient Rights Ombudsman, art. 24), safety, archiving, destroying
     • Two possibilities of keeping medical records: in paper or/and 
      electronic versions
      
                     TYPES OF MEDICAL RECORDS
                     individua      collective
                          l
               internal      external