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Guard / Archive images and reports: What doctors should know?

The purpose of this article is to gather, in a timely and systematic manner, the necessary guidelines on the subject of “keeping and archiving images and reports” - based on existing legislation and opinions on the subject. Here are the most relevant topics:

The examinations (films and reports), although sometimes receiving different treatment, are an integral part of the patient's medical record, pursuant to CFM Resolution No. 1638/02 and CFM Opinion No. 10/09.

The keeping of medical records, in turn, is regulated by CFM Resolution No. 1,821, of 11/23/2007, which establishes, in its article 8, the minimum period of 20 (twenty) years for preservation of medical records on paper. that has not been microfilmed or digitized, and in relation to the safekeeping of the digitized or microfilmed medical record it must be permanent, as established in article 7 of the same Resolution.

The responsibility of the physician and the service for the safekeeping of radiological examinations ceases with their removal by patients. However, a copy of the issued report should be filed, and the delivery of documents to the patient must always be formalized with a “withdrawal protocol”.

After scanning the exams according to the rules set out in Resolution No. 1,821 / 2007, it is possible to destroy the originals before the retention time has elapsed, provided that the computerized system fully meets the requirements of Security Assurance Level 2 (NGS2) established in the Certification Manual for Electronic Health Registration Systems, approved by the Federal Council of Medicine.

Article 86 of the Code of Ethics provides that the physician may no longer provide the medical report to the patient. In the same vein, the understanding contained in Opinion No. 26/2009 of the CRMPB, whose conclusion was the obligation to prepare the medical report (under penalty of ethical illicit).

 

Alan Skorkowski
CBR legal advice

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Simone Max

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