Lekarz Medycyny Pracy - numer specjalny (Doctor of Occupational Medicine) 2022/01 (02)

• Legal comments
  • Should documentation of occupational medicine be kept in electronic form (1)
    Does the obligation to keep electronic medical records also apply to occupational medicine records? If so, how to get the patient's signature on the preventive examination?
  • What is electronic medical documentation, and what is electronic medical documentation (4)
    Electronic medical records include e-prescriptions, e-referrals or information card from hospital treatment. Next to it, there is medical documentation in electronic form. What are the differences between these forms of medical records?
  • How to correct a medical documentation error (5)
    There can be mistakes in medical records, including occupational medicine. Check what to do when, for example, a mistake in the patient's name creeps into the files. What are the possibilities of improving the lapse?
  • Do the originals of occupational medicine documentation have to be made available (6)
    The occupational medicine doctor wants to find out how the restrictions on issuing original medical records apply to the activities of occupational medicine units, taking into account § 10 sec. 2 and 3 of the Ordinance of the Minister of Health of July 29, 2010 on the types of medical documentation of the occupational medicine service, the manner of its keeping and storage, and the templates of the documents used?
  • Which forms of securing e-medical records to choose (8)
    Modern technological solutions and appropriate procedures that will enable long-term storage of medical records are a necessity in medical institutions today. What requirements should IT systems for creating medical records meet?
  • When is it acceptable to keep paper medical records (9)
    Many medical institutions still have difficulties keeping medical records in electronic form. So when can medical facilities run it on paper? Learn about the exceptions to keeping electronic medical records.
• Forms
  • Instructions on how to complete a medical certificate for pupils and students (11)
  • What cannot be missing in the summary of the officer's medical and psychological tests - instruction (12)
  • A statement that there are no contraindications to work or that they exist - which must be remembered by the occupational medicine physician (14)
    Employers refer employees for initial, periodic and follow-up medical examinations. For this purpose, they issue a referral in duplicate. Find out what you need to keep in mind when completing paperwork for occupational medicine examinations.
• Checklist
  • Does electronic medical record keeping software keep it secure - checklist (16)

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