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A Journal on Forensic Medicine
Minerva Medicolegale 2001 March;121(1): 15-36
Medical records. Compilation, storage, filing, management and release by the health manager. Medical data processing and privacy. Juridical aspects and medicolegale problems
The medical record represents one of the basic elements through which the doctor's technical performance is integrated in the certification and administrative-type functions of the health service. Article 7 of Presidential Decree no. 128/1969 directly allocates the responsibility of regularly compiling medical records to the head of department. This is obviously an ''in vigilando'' responsibility that is normally completed when the record is ''closed'' before being forwarded for filing by the Health service management. There are no detailed legislative specifications relating to the methods used to compile these medical records in public hospitals, but those appliyng to private clinics (DPCM 27 June 1986) provide useful general guidelines. Article 35 of the latter decree states that the medical record should contain: the full name and personal data, diagnosis on admission, personal and family medical history, results of objective examinations, laboratory and specialist tests, diagnosis, therapy, outcomes and sequelae. The times taken to fill medical record should correspond to the literal meaning of updating the daily clinical sheet. It should include not only objective clinical findings and reasonably detailed description of the most important therapeutic and diagnostic procedures, but also subjective symptoms reported by the patient. Turning to the juridical qualification of the medical record as a ''public deed'', the stance taken by the Supreme Court has always been constant and uniform. This means that failure to manage the document correctly could lead to the severely primitive sanctions of Articles 328, 476 and 479 of the Penal Code.With regard to the lenght of time the medical record and its accessory documentation should be stored in the filing system of the Health service, circular no. 9000 2/AG 454/260 from the Ministry of Health, dated 19 December 1986, provides th following guidelines: medical reports must be kept indefinitely, and in the current files for the first forty years. X-rays and other diagnostic documentation must be kept for at least twenty years.