1. The maintaining of a medical file is an integral part of health care provisions. Maintaining of a medical record can be defined as the acquisition, collecting and recording of data. The medical file as a whole is maintained by the patient’s general practitioner. Other attending health care professionals maintain medical records regarding the health care provided by them. Medical records are maintained in a written form or in an electronic form with secured electronic signature
2. Medical records are defined as a set of data on the health condition of a patient or on the health care and health care related services provided to him. Besides this general formulation, the Act on Health Care determines the contents of the medical file in a more detailed manner.
3. The health care provider has not only to process and provide the medical file of the patient, but also to enable its access. The Act on Health Care enumerates those persons who have the right to access the patient’s medical file. The health care provider is allowed to refuse access to a medical file if the patient is provided with the health care in the specialized field of psychiatry or clinical psychiatry and the access to the medical records would negatively affect his treatment.
4. Each person who has the right to access the medical file also has the right to make extracts or copies to the extent that he has access.
5. A husband or wife, a child or a parent (or their legal representative) has the right to fully access the medical file of the patient after his death. In case there is no such person, the right to access the medical file shall be exercised by an adult person living with the patient at the time of his death or a relative (or their legal representative). The person who is entitled to access the medical records after the patient’s death shall also have the right to make extracts or copies from the medical file.
6. Correction of a report in the medical file is accomplished by a new entry consisting of the correction date, the corrected information and the identification of the attending medical professional who corrected the entry. Only the author of the original entry is entitled to correct his report. It is specifically required that the original entry must remain legible after the correction.