Case-histories have unquestionable legal importance, as it is shown by High Court Jurisprudence. This is due to the fact that it must report all the patient's process and disease, being thus the relationship doctor-patient completely transcribed (or at least all its relevant issues). So, in case of accusation, the most important evidence deciding doctor's sentence or acquittal will be within case-history. That is why the sentence "Case-history can be doctor's best allied, but also doctor's worst enemy" has been coined. In this setting one can understand perfectly how important the issue posed by this work is, since nowadays computers development offers to us a great number of advantages when collecting case-histories. This has made many health workers- and hospitals-think about keeping them in software. Actually, many of them have already been doing it for quite a long time. For this reason we are going to analyse this topic from a legal point of view, since legal standards provided by Law must be followed: preserve citizens' right to privacy and confidentiality. Security guidelines provided also by Law must be observed, which will allow to guarantee who the author of the document is (authentication) and that there has not been any later manipulation of data (integrity).

Acta otorrinolaringológica española

Medical Records Systems, Computerized - legislation & jurisprudence; Confidentiality; Humans; Malpractice; Physician-Patient Relations

MEDLINE; MEDLINE with Full Text; Medline Complete; PubMed; MEDLINE (Ovid)