4.1.08 Patient file Estimated reading: 1 minute 673 views Authors Download the VA as PDF Download Goal and purpose Creation, maintenance, finalisation, storage and archiving of records relating to the treatment of a patient. The general structure of a patient file should be defined in a procedural instruction. It must be clarified who is authorised to make entries, how data is presented, which individual documents from diagnostics and therapy are included, which symbols and abbreviations are used, etc. A standardised filing system should be found for all medical records in the hospital. The data entries must be created in such a way that they can also be entered in the computerised system. The treatment records must accompany the patient during treatment in hospital so that the staff involved always have access to the information required for treatment. In special cases, a patient-related report can be created. Patient-related medical reports must be included in the patient file. BGB § 630 f Area of application Description of the Documentation Resources Responsibility and qualification Notes and comments Applicable documents Literature Terms Attachments Table of contents of the patient fileDownload Main documentation formDownload 4.1 Documentation - Previous 4.1.07 Patient identification via barcode Next - 4.1 Documentation 4.1.09 Care documentation
