Inspection of the medical record

The patient can, with a written request to the healthcare organization, obtain an inspection of the medical file kept for him. In the request, you should specify the personal data you are looking for. Medical data is personal data relating to an individual’s health, including genetic data. Genetic data, on the other hand, are data that refer to the hereditary characteristics of the individual.

The patient has the right to request the correction, completion, deletion, clarification or renewal of personal data and medical data relating to him, which are incorrect, incomplete, unclear or outdated, or which are not relevant for the purposes of diagnosis, treatment and care, all in order to ensure fair processing of his personal data.

Confidentiality of personal data contained in the patient’s medical record

The patient has the right to the confidentiality of data relating to his health condition, medical, i.e. clinical condition, diagnosis, prognosis and treatment, as well as all personal data and other information, which must be kept in confidence, even after his death. in accordance with the regulations for keeping professional and business secrets, as well as for the protection of personal data.

The health organization or a person employed in the health organization must not disclose personal data about the patient, which he came across in the course of work.

According to the Law on Health Care (“Official Gazette of the Republic of Moldova No. 17/97), health workers, when providing health care, are obliged to take care of patients, respect their dignity, adhere to medical ethics and keep the professional secret.

The duty to keep professional secrecy also applies to other workers in health and other organizations who use medical documentation or in any way in the performance of their work tasks, will come to personal data contained in it.

Records in the field of health

According to the Law on records in the field of health , health organizations keep the following records:

  1. records of malignant diseases;
  2. diabetes records;
  3. records of ischemic heart disease;
  4. records of renal failure;
  5. records of psychoses;
  6. record of alcoholism and other addictions;
  7. record of occupational diseases;
  8. records of rheumatic fever;
  9. records of intoxications (poisonings);
  10. traffic trauma record.

According to the Law on records in the field of health, the following records are kept:

  1. records of systematic and periodic health examinations of the population;
  2. record of the state and measures for the protection and improvement of the human environment;
  3. records of the health correctness of food items and items for general use;
  4. records of births and terminations of pregnancy;
  5. records of family planning activities;
  6. records of immunization against infectious diseases;
  7. records of visits, health services, established diseases, conditions and injuries;
  8. records of infectious diseases;
  9. records of drug consumption;
  10. records of the receipt and issuance of narcotic drugs;
  11. records of users of narcotic drugs.

Records in the field of health are kept by the health organizations that will determine the disease, that is, that within the framework of their activity deal with the study and treatment of these diseases and other organizations that perform health activity.

Health organizations are: practices, health centers, health centers, hospitals, medical centers, institutes, institutes, clinics, clinical center, health care institute, pharmacies and natural healing centers.

Records in the field of health according to the Law on records in the field of health contain the following data:

  1. first name, last name and EMBG;
  2. gender;
  3. day, month and year of birth;
  4. marital status;
  5. occupation;
  6. place and address of permanent residence;
  7. type of health care;
  8. registration number and activity code;
  9. personal number of the health care insured;
  10. name of the obligor who bears the costs of the provided health care
  11. diagnosis (clinical, histological-cytological);
  12. date of the first establishment of the diagnosis;
  13. date of reporting the diagnosis;
  14. the stage of the disease (initial, advanced, terminal);
  15. metastases (do not exist, exist, localization);
  16. type of treatment (operative, radiation, chemotherapy, symptomatic); and
  17. treatment outcome.

Health organizations submit this data to the Republic Institute for Health Care.

The entry of data into the records is done based on the results of examinations and documentation of the health organization and other organizations, that is, based on public and other documents.

The data entered in the records of the visits, health services, established diseases, conditions and injuries are stored as data with permanent value.