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Documentació sanitària: veritat o mentida

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Documentació sanitària: veritat o mentida

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About this activity

Questionari Marina López-Pol Pardo

Created by

Marina López López
Marina López López
Spain

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Documentació sanitària: veritat o mentida
 

Documentació sanitària: veritat o mentidaOnline version

Questionari Marina López-Pol Pardo

by Marina López López
1

La història clínica hospitalària inclou dades d’identificació del malalt i l’assistència, així com dades clinicoassistencials.

2

En l’atenció primària la història clínica és sempre una història clínica hospitalària.

3

L’HC3 és només una base de dades en format paper.

4

La normativa de protecció de dades atorga una protecció especial a les dades relatives a la salut.

5

Un document està format per tres elements: el suport, la informació o contingut i el registre.

6

Tots els documents sanitaris són només clínics.

7

L’encapçalament d’un document inclou les dades d’identificació de l’hospital i del pacient.

8

Els arxius d’històries clíniques poden ser físics o electrònics i s’arxiven segons la llei.

9

No existeix cap distinció entre documentació clínica i no clínica.

10

L’alta voluntària mai implica signar per part del pacient.

 
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