Aunque este es un blog de podología y lo que más me gusta es hablar sobre clínica, ciencia, artículos científicos y todo lo que envuelve a nuestra profesión, no está mal hablar de las leyes que debemos cumplir en nuesta consulta en nuestra práctica diaria. El conocimiento de la normas legales y su cumplimiento en nuestras consultas es parte de nuestra profesión.
LEY 41/2002, DE 14 DE NOVIEMBRE, BÁSICA REGULADORA DE LA AUTONOMÍA DEL PACIENTE Y OBLIGACIONES EN MATERIA DE INFORMACIÓN Y DOCUMENTACIÓN CLÍNICA
Esta ley es una norma básica que entro en vigor seis meses después de su publicación, el 16 de mayo de 2003
Se estructura en 6 capítulos, 6 disposiciones adicionales, una disposición transitoria, otra derogatoria y una final.
CAPITULO I
Establece una serie de derechos y obligaciones al respecto de la documentación sanitaria
| RESPECTO A LOS PACIENTES |
|
| RESPECTO A LOS PROFESIONALES |
|
Además, también establece una serie de definiciones. Entre otras:
– CERTIFICADO MÉDICO: declaración escrita de un médico que da fe del estado de salud de un sujeto en un determinado momento.
– DOCUMENTACIÓN CLÍNICA: soporte que contiene datos de la información asistencial a un paciente.
– HISTORIA CLÍNICA: conjunto de documentos que contienen los datos, valoraciones e informaciones de cualquier indole sobre la situación y la evolución clínica de un paciente a lo largo de un proceso asistencial.
– INFORMACIÓN CLÍNICA: todo dato que permite obtener conocimiento sobre la situación clínica de un sujeto.
– INFORME DE ALTA MÉDICA: documento emitido por el facultativo responsable en un centro sanitario al finalizar el proceso asistencial que especifica los datos del paciente, resumen de su historial clínico, la asistencia prestada, el diagnóstico y las recomendaciones terapeúticas.
CAPITULO II
Este capítulo habla sobre el derecho que tiene el paciente a conocer toda la información disponible sobre su salud como resultado de una actuación sanitaria, que se recogerá en su historia clínica. Generalmente será oral.
También recoge el derecho a no ser informado y a que la información clínica sea VERDADERA, COMPRENSIBLE y ADECUADA de forma que le ayude a tomar decisiones sobre su salud. El titular del derecho a la información es el paciente. En caso de incapacidad también se debe informar en términos comprensibles, aunque también se debe informar a su representante legal.
En este capítulo también se habla del derecho a la información epidemiológica, de forma que los ciudadanos tienen derecho a conocer con veracidad los problemas de la generalidad en los mismos términos verdaderos, comprensibles y adecuados.
CAPITULO III
Este capítulo versa sobre el derecho a la intimidad con respecto a los datos de la salud. Los centros sanitarios deben garantizarlo.
CAPITULO IV
Seguramente el de más importancia para los podólogos. Establece el consentimiento informado, que de forma general será oral salvo en algunos casos que se hará por escrito:
– Intervención quirúrgica.
– Procedimientos diagnósticos y terapeúticos invasivos.
– Procedimientos que impliquen riesgos notorios o con previsible repercusión negativa sobre el paciente.
Puede ser revocado en cualquier momento. Cabe la representación de paciente. Y… ¿qué pasa con los menores?
Con 12 años debe ser escuchado. En el caso de un menor emancipado o mayor de 16 años decide él. Sólo ante una actuación de grave riesgo los padres deben ser escuchados y oídos.
Sólo no debe prestarse el consentimiento en caso de grave riesgo para la integridad física o psíquica del enfermo o de grave riesgo para la salud pública, casos poco probables en nuestra profesión sanitaria.
Aunque renunciemos al derecho de información no exime de dar consentimiento informado. Así mismo el paciente tiene derecho a conocer su participación en proyectos de investigación o docentes y derecho a decidir entre las opciones clínicas que existan.
CAPITULO V
Este capitulo detalla algunos aspectos acerca de la historia clínica de nuestros pacientes. Lo más importantes es que los centros las custodiaran diligentemente y con confidencialidad UN MÍNIMO DE CINCO AÑOS. El paciente tiene derecho de acceso a la información y a obtener copias. Eso sí, no tiene derecho a acceder a las anotaciones subjetivas de los profesionales.
También habla este capítulo acerca de que la recogida de información ha de hacerse de forma ordenada y secuencial, con criterios de unidad e integración y debe valer para conocer de forma veraz el estado de salud del paciente.
CAPITULO VI
Este último capítulo de la ley habla acerca de los informes de alta, siendo un derecho de todos los pacientes. Los pacientes que se nieguen al tratamiento deberan cumplimentar un documento de alta voluntaria.
BUENO SI HAS LLEGADO HASTA AQUÍ TE MERECES TODO MI RESPETO. A veces repasar estos temas se puede hacer muy muy farragoso. Resumen muy muy escueto:
– Información veraz y comprensible para nuestros pacientes.
– Firma del consentimiento informado para prodecimientos quirúrgicos e invasivos. Se que hay compañeros que lo hacen para las infiltraciones. En mi caso, para las no intraarticulares yo no lo hago.
– Niño con más de 12 años se le escucha, con más de 16 o menores emancipados pueden prestar el consentimiento.
– Informe de alta. En nuestro caso lo tenemos que rellenar en nuestros actos quirúrgicos. En los hospitales nos ofreceran el documento para rellenar al darle el alta a nuestro paciente.
Aquí podeis encontrar la ley publicada en el BOE sin resumir.
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