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The medical record in the Diagnostic Imaging services

Initially, it is necessary to establish in relation to the object of this article a fundamental premise: the examinations (films and reports) are an integral part of the patient's medical record, pursuant to CFM Resolution No. 1638/02 and CFM Opinion No. 10/09.

It should never be emphasized that 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 the preservation of medical records. paper record that has not been microfilmed or scanned, and in relation to the safekeeping of the scanned or microfilmed chart it must be permanent, as established in article 7 of the same Resolution.

The report, in fact, is an integral part of the examination. The Law clearly states that medical examination reports are an integral part of the medical record and must be archived for a period of 20 years (when in paper form) or permanently (when filed in a computerized system).

In this sense, the understanding contained in CFM Consultation Process No. 7,728 / 08:

“In the light of the above, in cases of examinations performed in radiological units not linked to a hospital establishment, where the patient does not seek to receive them to show them to the requesting physician, the guardian responsibility remains because they were produced as a result of their specific activities, The provisions of CFM Resolution No. 1,821 / 07 must be observed. The duty of custody in relation to the radiological examination ceases with its withdrawal by the patient, however a copy of the issued report must be filed. One possibility would be the mailing to the patient or legal guardian, upon acknowledgment of receipt. The personal delivery of the exams must be done by protocol. ”

On the other hand, in addition to the rules presented so far, an imaging clinic that is not linked to a hospital is not expected to form a conventional medical record, such as the one found in nosocomials.

In any case, making the examination and the report an integral part of a medical record, as well as the patient's clinical record, consent form or any other authorization signed by him, as well as any other complementary exams used to prepare the report, should clinic to preserve this information which, in effect, will constitute that patient's effective medical record, including for the appropriate legal purposes, if necessary.

Conclusion: all examinations (including the respective reports) are an integral part of the patient's medical records and, added to the other documents belonging to the patient (terms of consent, other examinations, etc.), constitute, in an imaging diagnostic service, the same. medical records.

CBR Legal Advisory

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Written by

Simone Max

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