Documentation violation
A documentation breach of duty is a violation of the treatment contractual obligation to document the treatment.
According to § 630f Abs. 2 BGB, the treating person is obliged to record in the patient file all measures and their results that are essential from a professional point of view for the current and future treatment, in particular the anamnesis , diagnoses , examinations, examination results, findings, therapies and their effects, Interventions and their effects, consents and explanations. Section 10 of the (sample) professional code also includes a documentation requirement, and Section 57 of the federal contract for contract doctors .
The documentation serves to ensure adequate co-treatment and follow-up treatment by other medical professionals, but is also a contractual secondary obligation to protect the patient's personal rights. At the same time, proper documentation can protect the doctor from reversing the burden of proof in the medical liability process.
If the treating person has not recorded a medically required essential measure and its result in the patient file, it is assumed that he did not take this measure ( Section 630h, Paragraph 3 BGB). In the opinion of the courts , the lack of records, which were required from a medical point of view, indicates that the measures in question have not been carried out. However, it is possible to provide evidence with other evidence , such as the witness evidence .
Web links
- Horst Dieter Schirmer, Marlis Hübner: Medical Documentation Obligations: The End of the Flag Pole Deutsches Ärzteblatt 2009; 106 (48): A-2408 / B-2073 / C-2013.
- Irina Neuleben: The medical documentation Kassenärztliche Vereinigung Nordrhein, accessed on June 21, 2020.
Individual evidence
- ↑ (Model) professional code of conduct for doctors working in Germany MBO-Ä 1997 - in the version of the resolutions of the 121st German Medical Association 2018 in Erfurt, amended by a resolution of the Board of Directors of the German Medical Association on December 14, 2018.
- ↑ Federal Sheath Treaty - Doctors from April 20, 2020.
- ↑ Documentation obligations and access rights to medical records. In: Reinhard Dettmeyer: Medicine & Law. Legal security for the doctor. Springer-Verlag, Berlin and Heidelberg 2006, pp. 117–141.
- ↑ Karin Comes: The rules of evidence of § 630h BGB in legal practice: The documentation deficiency Düsseldorf, 2016.
