“Physicians’ handwriting must be legible” in patients’ medical records according to the current version of Germany’s patients’ rights law, passed last year.
Frank Leopold, head of a Verein that advocates for medical patients, told Spiegel.de some other salient aspects of the patients’ rights law [German Civil Code, §630a et seqq.]:
Upon request, patients must be given access to view their full medical records, unless it could harm them or endanger the rights of third parties. If the patient so desires, this access must be granted directly after treatment, “without delay” [unverzüglich]. If physicians use the “harm” reason as grounds to refuse patients access to their full medical records, an appropriate diagnosis must have been made.
Patients have the right to get copies of their medical records, though the patient must pay for the copies.
Everything in a patient’s medical record must be left there. Any corrections and changes must be made so that the original content is still apparent, and must be signed and dated by the physician.
Software that keeps medical records must meet the same requirements. All changes and original content must remain apparent.
Handwriting in medical records must be legible, even physicians’ handwriting.
Mr. Leopold was skeptical about preventing manipulation to electronic records, but said he didn’t know enough about the software to comment.
He said it’s important to talk about this in public fora, because it’s important for patients and physicians to know patients’ current rights, to prevent confusion.
(HONNED shrift dess OTTS tess moose LAZE bah z eye n.)