[记录的重要性,未记录即视为未完成]。

Die Anaesthesiologie Pub Date : 2024-09-01 Epub Date: 2024-08-09 DOI:10.1007/s00101-024-01441-1
Sarah Göpfert
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引用次数: 0

摘要

只有少数医生愿意在实践活动之外,全面关注如何构建法律上无懈可击的治疗文件;然而,文件的重要性无论如何强调都不为过,这不仅关系到潜在的责任案件,也关系到医疗(进一步)治疗。因此,本文阐述了强制性文件的法律基础以及与之相关的最重要的实践问题,特别是文件的内容、文件的时间、治疗文件的保存以及在即将发生事故时的行为。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
[Importance of documentation. Not documented is deemed to be not done].

Only a few physicians are willing to comprehensively concern themselves with how a legally watertight treatment documentation should be structured, in addition to their practical activities; however, the importance of the documentation cannot be emphasized enough, not only for a potential case of liability but also for the medical (further) treatment. This article therefore illustrates the legal foundations of the mandatory documentation and the most important questions associated with it for the practice, in particular on the content of the documentation, the timing of the documentation, the preservation of treatment documents and on the conduct in cases of an impending incident.

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