Record keeping and documentation
Health data is among the most sensitive information that exists
At a clinic, you handle some of the most sensitive information that exists about a person: health, treatments, maybe medicine, and diagnoses. This is protected in two ways – by the duty of confidentiality in the health service and by data protection rules (GDPR / the data protection regulation). Both are not optional politeness but rules you must know and live by.
§The journal
There is an obligation to keep records of patient treatment. The journal is both documentation of what has been done and a working tool that ensures continuity so the next clinician knows where to start. A good journal entry is objective precise and written at the right time — not a memory exercise the day after.
- 01Note treatments, agreements and relevant observations correctly and promptly.
- 02Write objectively and professionally – the journal can be read by others, including the patient themselves.
- 03Do not correct in a note so the original disappears; corrections must be visible.
- 04Before also documentation of self-monitoring, e.g. hygiene and sterilization.
§Confidentiality obligation
The confidentiality obligation covers everything you learn about patients — not only diagnoses but also that a particular person is a patient at all. It applies even outside working hours and after employment has ended. Never talk about patients where others can hear it and never share information without a legal basis.
§GDPR in everyday life
GDPR sets the framework for how personal information may be processed. The most important principles for you to know are that information may only be used for the purpose it was collected for, only the necessary information should be collected, and only the employees who need it for their work may see it.
| GDPR principle | What it means in the clinic |
|---|---|
| Purpose limitation | Patient data is used for treatment and operation – not for anything else |
| Data minimization | Collect and note only what is necessary |
| Access restriction | Only staff who need it open a journal |
| Confidentiality and security | Screens are locked, paper is put away, nothing is shared without reason |
| Sletning/opbevaring | Data is retained and deleted in accordance with applicable rules and deadlines |
§Practical habits that protect data
- 01Lås computerskærmen, når du forlader den, og del ikke logins.
- 02Læg papirjournaler og print væk, så de ikke ligger fremme.
- 03Never send patient information via insecure channels.
- 04Only look up patients you have a professional reason to see.
§When the patient asks for insight
Patients have the right to access their own information. Always contact the person responsible at the clinic about such inquiries so they are handled according to the rules. It is not something you should decide on your own at the counter.