Patient’s Medical Records in Brazil: Legal and Regulatory Considerations

Abstract

This work aimed to research medical records' legal and regulatory definitions as found in force not only in the Brazilian normative systems but also at the Federal and Regional Councils of Medicine (Conselho Federal e Conselhos Regionais de Medicina), particularly their completeness to be accepted by the judicious system. This empirical retrospective documentary research recovered norms, legislations, resolutions, and professional opinions about medical records and some of its parameters, such as content, legibility, and accountability using official legal and regulatory digital platforms. No period limitation was set for document recovery; however, only current ones (still in force) were analyzed in full. Documents that dealt with the content of the medical record per se were included; those that dealt with custody, confidentiality, digitization, and access to third parties were excluded. The Brazilian legislation does not provide a clear definition of medical records or their core content. Nonetheless, its collective nature is recognized. The Federal and Regional Councils of Medicine have issued numerous resolutions and opinions on the matter, clarifying its completeness in nature. Medical Records are a collection of health documents of a patient, which should be readily available upon court request as a complete medical dossier, and must contain legible and signed copies, including all the procedures a person underwent while under care.