Publication: Tıbbi kayıtlar
Abstract
TIBBİ KAYITLAR Tıbbi kayıt, hekim veya diğer sağlık personelince hazırlanan, hasta veya üçüncü kişilerce verilen bilgilerden hareketle yahut hekimce gerçekleştirilen teşhis ve tedavi faaliyetine ilişkin değerlendirmeleri sonucu oluşturulan, tıbben öngörülmüş amaçlara hizmet eden, kağıt veya elektronik ortam üzerine kaydedilmiş her türlü bilgi ve belgedir. Kişilerin sağlık durumları ve hastalıkları ile kendilerine yönelik olarak gerçekleştirilen tıbbi müdahale niteliğini taşıyan her türlü faaliyetin doğum öncesi dönemlerinden başlayarak ölünceye kadar düzenli ve eksiksiz tutulması, ayrıca bunların kaydedilmesi ve saklanması hastalar için en az ilaçlar ve tedaviler kadar önemlidir. Bu önem karşısında tıbbi kayıtlar, sağlıklı toplumu oluşturacak sağlıklı bireyler yetiştirilmesi açısından vazgeçilmez bir nitelik taşırlar. Hasta ile hekim arasında geçerli tedavi sözleşmesinde tıbbi kayıt tutma yükümlülüğü taraflar aksini kararlaştırmadıkça bir yan edim yükümlülüğü olarak karşımıza çıkar. Tıbbi standardın gerektirdiği her husus aynı zamanda kayıt altına alınır. Sağlık hizmetlerinden faydalanmak amacıyla hekime veya sağlık kuruluşuna başvuran herkesin kendisine ait tıbbi kayıtlara erişim, bunları inceleme ve gerçeğe uygun hale getirilmesini isteme ile suret alma hakları bulunmaktadır. Tıbbi kayıtların hukuka uygun olarak tutulmamasının hem özel hukuktan hem de ceza hukukundan doğan sorumluluğu gerektirir sonuçları ortaya çıkabilir. Tıbbi kayıtların hukuka uygun olarak tutulmaması halinde zarar gören hasta veya yakınları, ilgililerin sorumluluğuna gidebilirler.
MEDICAL RECORDS Medical records are all kind of information and documents that are recorded on a paper or electronically and prepared by the doctor or the other medical personnel according to the information given by the patient or the third persons or the result of the evaluations of the doctor regarding the diagnosis and treatment serving for the medically projected aims. It is as much as important as the medicines and treatments for the patients that all the activities that constitute a medical intervention and all the information regarding their health conditions and diseases starting from prenatal period till death are kept regularly and completely. Having this importance, medical records are essential for bringing up healthy individuals that would constitute a healthy society. Unless the parties agreed on the opposite, the obligation to keep medical records is subsidiary liability in the valid contract between the doctor and the patient. All the aspects that the medical standard requires are also recorded. Everyone that consult to a doctor or a healthcare organization for taking medical service has the rights to access to the medical records, to examine them, to ask for correction, and to take a copy from the records. In case of medical records are not kept in accordance with law, there might be consequences because of the responsibility in compliance both with the private law and penal law. The patients or the patient relatives that are damaged as a result of the non-statutory medical record keeping can bring an action. Medical record, medical law, privacy, health legislation.
MEDICAL RECORDS Medical records are all kind of information and documents that are recorded on a paper or electronically and prepared by the doctor or the other medical personnel according to the information given by the patient or the third persons or the result of the evaluations of the doctor regarding the diagnosis and treatment serving for the medically projected aims. It is as much as important as the medicines and treatments for the patients that all the activities that constitute a medical intervention and all the information regarding their health conditions and diseases starting from prenatal period till death are kept regularly and completely. Having this importance, medical records are essential for bringing up healthy individuals that would constitute a healthy society. Unless the parties agreed on the opposite, the obligation to keep medical records is subsidiary liability in the valid contract between the doctor and the patient. All the aspects that the medical standard requires are also recorded. Everyone that consult to a doctor or a healthcare organization for taking medical service has the rights to access to the medical records, to examine them, to ask for correction, and to take a copy from the records. In case of medical records are not kept in accordance with law, there might be consequences because of the responsibility in compliance both with the private law and penal law. The patients or the patient relatives that are damaged as a result of the non-statutory medical record keeping can bring an action. Medical record, medical law, privacy, health legislation.