Medical records and documents
Articles in the “Medical records and documents” category of the Mi Clínica blog.
Medical records and documentsPatient reports and test results: where to store them
The reports, blood tests and other tests a patient brings or sends are part of their medical record. Why, what goes wrong when they stay in email or on a phone, a routine for adding them, who can see them, how long they are kept and how images are attached in Mi Clínica.
· 6 min read
Medical records and documentsSpain's Law 41/2002 on patient autonomy: a guide for clinics
What Spanish Law 41/2002 asks of a private clinic, in three areas: information for the patient, consent and the medical record, plus the duties that get forgotten (discharge report, certificates) and a checklist to go through with your team.
· 8 min read
Medical records and documentsPrescription in PDF or electronic prescription: what each one is
The difference between a medical prescription, with the requirements of Real Decreto 1718/2010, and a “Receta” (Prescription) PDF document made with management software: who can issue a medical prescription, what the rule requires on paper and electronically, and what Mi Clínica's “Nueva receta” (New prescription) does and does not do.
· 7 min read
Medical records and documentsCopy of the medical record: how to handle a patient's request
When a patient asks for a copy of their medical record, the clinic has to check who is asking, reply within the general one-month deadline, review third-party reservations and subjective notes, deliver it by the right means and keep a record of everything.
· 8 min read
Medical records and documentsPatient record alerts: what should be visible before you start
Patient record alerts warn the team, before they see the patient, about an allergy, that the patient is a minor and who their guardian is, a document awaiting signature or an outstanding payment. What they are, which ones must be visible, where they come from and how to keep them up to date.
· 7 min read
Medical records and documentsHow long must a medical record be kept in Spain?
The national minimum is five years from the date of discharge from each care process, within the time appropriate to each case. When records are kept longer, the role of the autonomous communities, who is responsible for custody and what to do when the period expires.
· 8 min read
Medical records and documentsElectronic medical records: what they must contain under Spanish Law 41/2002
The electronic medical record is the same one regulated by Spanish Law 41/2002, in any format. What defines it, what minimum content it sets and which sections are tied to hospital admission, how to digitise paper records and what Mi Clínica does, and does not do, to store it.
· 8 min read
Medical records and documentsBody charts in physiotherapy and aesthetics: one version per visit
The body chart is the drawing of the body or face on which what is noted at each session is marked. What it is, why it is part of the record, why save one version per visit, how to agree a shared legend and how it works in Mi Clínica.
· 7 min read
