{"id":10727,"date":"2024-12-11T14:30:08","date_gmt":"2024-12-11T13:30:08","guid":{"rendered":"https:\/\/extali.eu\/docs\/4-informationswesen\/4-1-dokumentation\/4-1-08-patientenakte\/"},"modified":"2025-01-31T22:06:17","modified_gmt":"2025-01-31T21:06:17","slug":"4-1-08-dossier-du-patient","status":"publish","type":"docs","link":"https:\/\/gutehospitalpraxis.de\/fr\/handbuch\/4-informationswesen\/4-1-dokumentation\/4-1-08-patientenakte\/","title":{"rendered":"4.1.08 Dossier du patient"},"content":{"rendered":"
T\u00e9l\u00e9charger l'AP au format PDF <\/a>T\u00e9l\u00e9charger<\/a><\/div>\n\n\n\n

Objectif et but<\/h2>\n\n\n\n

Cr\u00e9ation, tenue, cl\u00f4ture, conservation et archivage des dossiers relatifs au traitement d'un patient.<\/p>\n\n\n\n

La structure g\u00e9n\u00e9rale d'un dossier de patient doit \u00eatre d\u00e9finie dans une proc\u00e9dure. Il faut pr\u00e9ciser qui peut faire des entr\u00e9es, comment les donn\u00e9es sont pr\u00e9sent\u00e9es, quels documents individuels de diagnostic et de th\u00e9rapie en font partie, quels symboles et abr\u00e9viations sont utilis\u00e9s, etc. Un syst\u00e8me de classement uniforme doit \u00eatre trouv\u00e9 pour tous les dossiers m\u00e9dicaux de l'h\u00f4pital.<\/p>\n\n\n\n

Les entr\u00e9es de donn\u00e9es doivent \u00eatre cr\u00e9\u00e9es de mani\u00e8re \u00e0 permettre une saisie \u00e9galement dans le syst\u00e8me informatique.<\/p>\n\n\n\n

Les dossiers de soins doivent accompagner les patients pendant leur traitement \u00e0 l'h\u00f4pital, de sorte que le personnel impliqu\u00e9 ait toujours acc\u00e8s aux informations n\u00e9cessaires pour le traitement. Dans des cas particuliers, un rapport sp\u00e9cifique au patient peut \u00eatre \u00e9tabli.<\/p>\n\n\n\n

Les rapports m\u00e9dicaux relatifs aux patients doivent \u00eatre vers\u00e9s au dossier du patient.<\/p>\n\n\n\n

BGB \u00a7 630 f<\/p>\n\n\n\n

Champ d'application<\/h2>\n\n\n\n

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Description<\/h2>\n\n\n\n

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Documentation<\/h2>\n\n\n\n

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Ressources<\/h2>\n\n\n\n

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Comp\u00e9tence et qualification<\/h2>\n\n\n\n

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Remarques et commentaires<\/h2>\n\n\n\n

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Documents \u00e0 joindre<\/h2>\n\n\n\n

Litt\u00e9rature<\/h4>\n\n\n\n

Termes<\/h4>\n\n\n\n

<\/p>\n\n\n\n

Placements<\/h3>\n\n\n\n
Table des mati\u00e8res du dossier du patient<\/a>T\u00e9l\u00e9charger<\/a><\/div>\n\n\n\n
Fiche de documentation principale<\/a>T\u00e9l\u00e9charger<\/a><\/div>\n\n\n\n

<\/p>","protected":false},"excerpt":{"rendered":"

Ziel und Zweck Anlage, F\u00fchrung, Abschluss, Aufbewahrung und Archivierung von Aufzeichnungen zur Behandlung eines Patienten. In einer Verfahrensanweisung soll der allgemeine Aufbau einer Patientenakte festgelegt werden. Gekl\u00e4rt werden muss, wer Eintr\u00e4ge machen darf, wie Daten dargestellt werden, welche Einzelunterlagen aus Diagnostik und Therapie dazugeh\u00f6ren, welche Symbole und Abk\u00fcrzungen benutzt werden, usw. F\u00fcr alle Krankenakten des […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":10711,"menu_order":8,"comment_status":"open","ping_status":"closed","template":"","doc_tag":[],"doc_badge":[],"class_list":["post-10727","docs","type-docs","status-publish","hentry","no-post-thumbnail"],"acf":[],"author_avatar":"https:\/\/secure.gravatar.com\/avatar\/c6b2616140d9fcd6a1c5d6d2ebbf43422308c9322c032ef03f88ec3235855dcf?s=96&d=mm&r=g","author_name":"admin","_links":{"self":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs\/10727","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs"}],"about":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/types\/docs"}],"author":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/comments?post=10727"}],"version-history":[{"count":1,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs\/10727\/revisions"}],"predecessor-version":[{"id":14956,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs\/10727\/revisions\/14956"}],"up":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/docs\/10711"}],"wp:attachment":[{"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/media?parent=10727"}],"wp:term":[{"taxonomy":"doc_tag","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/doc_tag?post=10727"},{"taxonomy":"doc_badge","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/fr\/wp-json\/wp\/v2\/doc_badge?post=10727"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}