Medical documentation

Primary records: outpatient card, consents, discharge summaries. In eHealth systems — electronic medical records; paper duplicates consents.

Informed voluntary consent before every intervention: diagnostics, procedure, anesthesia. Written form + patient signature + date.

Medical secrecy is special-category data: role-based access, access logs, encryption. A patient data leak is the clinic's liability.

Records — 25 years outpatient, longer for inpatient. Electronic archive with backup. Destruction — by act, not 'in the trash'.

Who signs what: doctor — records/summaries, admin — referrals/receipts, chief physician — statutory docs. Delegation — by order, not verbally.

NHSU audits reports + records against declarations. The health authority checks licensing conditions: forms, consents, sterilization logs.