Health Legislation, Normative and Health Regulations

Health Specific Legislations Aplicable to the Helth Fields and the HIS, as wel as other Rules, Regulations or Legal Dispositions Acording to the Internal, Institution, Local, Regional or National Aplication.

Above all, we want to manifest our deep conviction that, in order to achieve operational excellence on the health systems and on the health institutions and organizations, it is essential to dispose and, if necessary, elaborate and approve certain regulations, rules and legal dispositions that regulates access and use of the clinic systems of information as well as the records, elaboration, uses, treatments, sessions, protection and personal data conservation, clinic data rewarding health (Electronic Medical Records (EMR), Documentation and Electronic Clinical History (ECH)) and general health data bases in general.

At THCG we lead the elaboration of the following rules, regulations and legal’s dispositions specific to the health field and assist in order to develop them. As a minimum a users handbook must be establish and regulate the following:

  1. Patient autonomy basic regulating rule.

  2. Patients and professionals obligations, guarantees, rights, basic regulating rule, rewarding information, management and handle the EMR & ECH including health documentation.

  3. Users data registration rules on the HIS including a procedure for the correct patient first and last name registration

  4. Rules to be able to identify without any mistake patients identification and a safe connection to the ECH. Identification number from ECH and their connection to the patient through the ICU number

  5. Safe identification of the health institution data, patient personal data including medical coverage data, affiliation data, address data, reference contacts data, and others health associates data.

  6. Clinic documentation identification procedure and their connection with EMR & ECH.

  7. Control rules of access, uses, protection, custody, conservation, loan and personal data assignment, of the clinic documentation and clinic data related with health including videos, images and others HIS data and at the EMR & ECH.

  8. Rules for personal data and clinic data related with the health state confidentiality and protection. Health organization staff obligations regime , including a statement about privacy and access confidentiality commitment and system information uses including personal data, clinic data and from other applications.

  9. Basic structure regulating rules and content of the basic group of the Minimum basic Data Set (MDS) included in the ECH reports: hospital discharge clinical report, emergency clinical report, surgery clinical report and other ambulatory procedures, external consults clinical report, primary attention clinical report, lab testing clinical results reports, image testing results reports, nurse care reports and the ECH summary.

  10. Data and clinical documentation rules. Data creation, completion, handling, cancelation or modification regime.

  11. Management and Inform Consents (IC) rules.

  12. Rules for the conservation, expurgation and partial elimination (documentation) or total elimination of the clinic chart at any given support, electronic (ECH), digital (DCH) at a paper support (PCH).

  13. Rules for the management and electronic, digital and paper support organization.

  14. Basic regulating rules for the hospitals discharge records (MDS) and the coding of the hospital activity care (Illness International Classification: CIE.9.MC / CIE.10.MC …)

  15. All hospital commissions regulating rules: clinical history commission, mortality commission, quality commission, infections illness commissions …

  16. Management and emergency patients flux regulation (admission / discharge).

  17. Hospitals beds management rules

  18. Management and O.R. schedule rules.

  19. External consults schedule and management rules.

  20. Rules for the clinical excellence development and implementation, through guidance and clinical ways with the objective of improving the service quality and reduce the care variability.

  21. Rules for the clinical excellence development and implementation through health’s politics and practice intended to improve the clinical safety of the patient in all the hospital care areas:

  • Emergency patient security.
  • Hospitalized patient security.
  • Intensive Care Unit (ICU) patient security.
  • O:R. patient security.
  • External consults patient security.
  • Security clinical care alerts system implementation, including the management regime and clinical alerts notification in hospitals and pre-hospital as well.
  • Information system implementation to notified adverse effects cause during the time the patient stayed in any of the health care facilities (hospitals, specialized care center, primary attention center, emergency centers, …)
  1. Health excellence encouragement rules, through the implementation of health politics and practice meant to improve the health security of the population and all the citizens. To implement an information system to notified and manage the public health alerts, including all compulsory notification illness. Notification and management of all epidemiological l alerts regime.

  2. Others rules and regulations related with health and health systems.