Dossierplicht: overdracht of afschrift
DOI: 10.5177/ntvt.2013.06.13120 Bladzijden: 301-305
Illustrator: Ron Slagter
De wet verplicht elke zorgverlener en dus ook tandartsen een dossier bij te houden. De meeste regels over de dossierplicht staan in de Wet op de geneeskundige behandelingsovereenkomst. En, zoals vaker het geval met wetten, de interpretatie wordt overgelaten aan de (tucht)rechter. Er is vooral veel jurisprudentie over welke informatie in het dossier thuishoort. Niet zelden trekt een tandarts in een procedure aan het kortste eind omdat zijn verweer niet ondersteund wordt door het dossier. En als blijkt dat (een deel van) het dossier vernietigd is, ondanks de wettelijke bewaarplicht, dan kan ook dit op weinig sympathie van de rechter rekenen. In een recente uitspraak stelt het Centraal Tuchtcollege voor de Gezondheidszorg zich strikter op dan ooit. Met verstrekkende gevolgen, en niet alleen voor de betrokken tandarts.
Requirements regarding health records: transfer or copy
Dutch law requires every healthcare provider, which obviously includes dentists, to maintain health records. Most of the rules governing the health record requirement are in the Law of Agreement to Medical Treatment (WGBO). And, as is often the case with the law, interpretation is left to the (disciplinary) judge. There is, in fact, a considerable amount of legal precedent concerning what information belongs in the health record. It is not uncommon for a dentist to be on the losing side in a legal proceeding because his defence is not supported by the health record. And if it becomes clear that (a portion of) the health record has been destroyed, despite the legal requirement to maintain records, in this too the dentist can count on little sympathy from the judge. In a recent judgment, the Central Disciplinary Committee was more severe than ever – with far-reaching consequences for the relevant dentis
Requirements regarding health records: transfer or copy
Dutch law requires every healthcare provider, which obviously includes dentists, to maintain health records. Most of the rules governing the health record requirement are in the Law of Agreement to Medical Treatment (WGBO). And, as is often the case with the law, interpretation is left to the (disciplinary) judge. There is, in fact, a considerable amount of legal precedent concerning what information belongs in the health record. It is not uncommon for a dentist to be on the losing side in a legal proceeding because his defence is not supported by the health record. And if it becomes clear that (a portion of) the health record has been destroyed, despite the legal requirement to maintain records, in this too the dentist can count on little sympathy from the judge. In a recent judgment, the Central Disciplinary Committee was more severe than ever – with far-reaching consequences for the relevant dentis