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保存还是销毁?病历对既往患者和未来患者的重要性

[Save or destroy? The importance of medical record for former patients and future patients].

作者信息

van Leeuwen F E, Schornagel J H

机构信息

Afd. Epidemiologie, Nederlands Kanker Instituut/Antoni van Leeuwenhoek Ziekenhuis, Plesmanlaan 121, 1066 CX Amsterdam.

出版信息

Ned Tijdschr Geneeskd. 2001 Mar 10;145(10):455-60.

Abstract

In 1995, a new privacy law was introduced in the Netherlands. According to this law, medical records should be saved for 10 years, and then destroyed, unless keeping the records for a longer period follows reasonably from the duties of the treating physician (as is the case, for example, when treating patients with a chronic disease). There are serious concerns with regard to the future availability of medical record data for clinical research and patient care after 2005. Evaluation of the late effects of many medical treatments will no longer be possible in the Netherlands. Patient care, particularly genetic counselling, will be also seriously compromised. As a possible solution the profession might name diagnoses and treatments regarding for which, from the point of view of good care, it is necessary for files to be kept for longer than 10 years. For a uniform nationwide policy it would be better if all files, perhaps after sorting by diagnosis and treatment, should be obligatorily kept for much longer than 10 years, preferably for the duration of the life expectancy.

摘要

1995年,荷兰出台了一项新的隐私法。根据该法律,医疗记录应保存10年,然后销毁,除非从治疗医生的职责来看有合理理由需要保存更长时间(例如,治疗慢性病患者时就是这种情况)。人们对2005年后临床研究和患者护理所需医疗记录数据的未来可用性深感担忧。在荷兰,评估许多医疗治疗的远期影响将不再可行。患者护理,尤其是遗传咨询,也将受到严重影响。作为一种可能的解决方案,该行业或许可以列出那些从优质护理的角度来看,有必要将档案保存超过10年的诊断和治疗项目。为了制定统一的全国性政策,或许所有档案在按诊断和治疗分类后,最好强制保存远超10年的时间,理想情况是保存至预期寿命结束。

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