Via practica 6/2017

GP `s card file – basic documentation of patients – everlasting problem?

The ability to document the physician‘s procedures in providing health care to patients in conditions of transforming healthcare becomes a major problem, particularly from the point of view of the quality of health care, the possibility of its assessment.It is necessary to acknowledge the awareness of the broad medical community that the correct management of medical records, enrollment of doctors in the hospital, primary and specialist outpatient care is a prerequisite for professional good practice, well - kept registration can be a reliable protection of a doctor in disputed cases.For a full focus on professional activities, it is a prerequisite to create organizational and operational assumptions, to discourage diversified activities that excessively burden physicians, shorten the time that can be used for patient care.The dynamic development of society and medicine, the rising demands of patients for healthcare provide reflection on the new paradigms of today‘s medicine, which are apparently demanding an adequate legislative underpinning, corresponding to the reality of the work of health workers.

Keywords: general medical practitioner for adults, health documentation, registration of provided health care, quality of documentation management