Documentación clínica. Aspectos legales y fuente de información para las bases de datos hospitalarias

Healthcare legislation on patient information and clinical documentation and on the rights and obligations of patients has evolved during the last 25 years in tune with changes in Spanish society. There are two fundamental laws that frame the overall context: constitutional law on the protection of personal data, and statute law regulating patients' autonomy and their rights and obligations with regard to information and clinical documentation. Here, we describe the most important points that physicians should be aware of because they could have an influence on clinical practice. From another perspective, clinical documentation provides the main source of information for hospital databases, and a substantial amount of information from medical records is stored in computerized databases. The physician should be aware that any clinical database must be entered on an official register of databases, that someone must be designated as being responsible for the database, and that any transfer of data is limited by the appropriate law. This article also contains descriptions of the most important hospital databases: the Minimum Basic Data Set, Diagnosis- Related Groups, patients' files, and cancer registers.