Understanding Files and Their Importance in Healthcare

Posted on Jun 8, 2024 in Law & Jurisprudence

FILE:

In reality, a file encompasses three key aspects:

  1. An organized collection of documents.
  2. The designated location for storing these documents.
  3. The institution responsible for managing them.

The International Council on Archives (1988) provides three definitions of a file:

  1. A collection of documents, irrespective of their date, format, or physical medium, created or received by an individual or entity during their activities. These documents are preserved by their creators or successors for their own use or transferred to a competent archival institution for retention or disposal based on their archival value.
  2. An institution tasked with the collection, processing, inventorying, preservation, and provision of access to documents.
  3. A building or a designated area within a building where documents are stored and accessed.

OTHER DEFINITIONS OF FILE

  • H. Jenkinson (1947): Files consist of documents accumulated naturally during the course of conducting any type of business (public or private), regardless of the date, and subsequently preserved for future reference under the custody of those responsible for the matters documented.
  • The Spanish Historical Heritage Act defines files as organized sets of documents, either individual documents or groups of related documents, assembled by legal entities, whether public or private, in the course of their activities. These files serve as resources for research, culture, information, and administrative management.
  • A. Heredia: A file comprises one or more sets of documents, regardless of their date, format, or material, accumulated naturally by an individual or a public or private institution during their operations. These documents are preserved to serve as evidence and information for the individual or institution that created them, or for citizens as historical sources (e.g., a letter from the FCB Foundation).

Elements that Characterize a File:

  1. Libraries: The complete collection of documents within a file.
  2. Producer: The individual or entity responsible for creating the document, such as a person, family, public or private organization, or a department within an organization.
  3. Genesis: Documents are created over time as an organization carries out its daily functions. These activities are documented and accumulated.
  4. Information: The data and information contained within the records that fulfill the needs of the producer.
  5. Conservation: Documents are preserved in a suitable environment, either by the producing entity or a competent archival institution, to ensure their long-term survival. They are organized to facilitate the retrieval of information.
  6. Processing Archive: A team of experts responsible for the practical aspects of file management and document processing.

ARCHIVE REPORT:

An archive report is a collection of written, graphic, image-based, or other types of documents in which healthcare professionals record observations, notes, and certificates related to patient interventions, as mandated by health regulations. Maintaining accurate and complete archive reports is a legal requirement for public, social, and private healthcare providers within the national health system.

Definition according to Orencio Lopez Dominguez (1997): The archive report serves as the operational unit responsible for collecting, preserving, and managing all printed, written, or pictorial materials generated during successive healthcare processes. It acts as a central repository for clinical surveillance data, ensuring the preservation and accessibility of this material.

INFORMATION REQUIRED FOR THE DEVELOPMENT AND OPERATION OF A HEALTH CENTER (2 TYPES):

  • Internal Information: Information generated by the healthcare center itself during the provision of healthcare services to individuals with health issues. This includes information processed during administrative processes and medical tests. There are two types of internal information:
    1. Documents related to logistical services: Invoices, receipts, and purchase orders for various materials. This documentation is managed by the administrative file.
    2. Clinical Administrative Documents: Directly related to patient care. This documentation is maintained by the UDC (Clinical Documentation Unit).
  • External Information: Documentation obtained from sources outside the healthcare center that is useful for its activities but not produced by the center itself. Examples include scientific journals, research papers, and grey literature. Hospital libraries are responsible for disseminating this information to healthcare professionals.

CLINICAL FEATURES OF A FILE:

  1. The archival unit is the clinical history.
  2. It is produced by healthcare professionals to support patient care.
  3. It is generated over time as medical care is provided.
  4. The data contained within the clinical history serve as a source of information for daily medical practice, teaching, research, legal advice, epidemiological assessments, healthcare quality management, resource allocation, and as a historical record.
  5. Clinical histories are stored in an organized and accessible manner to ensure efficient retrieval of information.