Medical record

• Primary record

  Form 025/o: complaints, anamnesis, objective findings, diagnosis, plan — physician signature on each entry.

• E-record

  In the EHS: a care episode with mandatory fields; data is confidential, role-based access.

• Informed consent

  A separate consent per intervention: diagnosis, risks, alternatives — patient signature before the procedure.

• Retention

  Paper records — 5+ years by type, e-records — in the EHS; issue to the patient on request.

A chart entry is the only proof in a dispute: 'not recorded = not done'. Every patient contact must end with a dated, signed entry.