Dudas de enfermería en el manejo de la historia clínica aspectos jurídicos

Abstract

As part of the changes produced within the nursing profession, the registration of the activities carried out proves to be necessary for the management of quality care, keeping in mind the legal aspect and development of nursing training. According to Spanish Act 41/2002, clinical history is the array of documents related to the care process of every patient, including the identification of doctors and health professionals that have intervened in the care. Its objective is to facilitate sanitary care, paying attention to aspects such as training and research, evaluation of the quality of care, administration and medical-legal. The Spanish Act 41/2002 determines which documents are obligatory and should be present in the clinical history. Among these are the care planning sheets, the records of therapeutic work and vital signs. All these should be present in each one of the moments along with the correspondent identification of the people carrying out the action, as these imply legal responsibility, as long as law compliance is guaranteed. Therefore, nursing must understand and fulfill the regulation regarding the use of clinical history. Nursing records are the documental tool where all the information of nursing activity is collected regarding a specific patient, assessment, received treatment, and progression. Nursing records are an essential part of the clinical history and therefore, have similar functions; the main one being treatment, focused on providing maximum quality care, as well as the researcher-trainer, management and contribution to the development of our profession. Other objectives are legal because the records are the documented testimony of the professional actions upon the Court requirements.