Record keeping is voluntary and is not mentioned in the training
What you need to document, and why confidentiality applies
Every examination you perform must be documented so that the doctor and other healthcare professionals can use the result — and so the patient is protected. The requirements for documentation are not something each department makes up on its own; they are set out in the law.
§Record keeping, confidentiality and GDPR at the clinic
The regulation on authorized healthcare professionals' patient records (record-keeping regulation, cf. retsinformation.dk) establishes that anyone performing healthcare tasks has a duty to document what tasks have been performed and planned, and to describe the patient's condition. A patient record must include information about the patient's condition, the planned and performed treatment/examination and what information the patient has been given and whether the patient has given consent.
§What must you document after an examination?
- 01What examination has been performed, and when.
- 02Any special conditions, e.g. that the patient was restless or an exposure had to be repeated.
- 03Technical parameters where relevant, e.g. which discharges or settings were used.
- 04Who performed the examination — you are responsible for the content of your own notes.
§Confidentiality obligation and data protection
As an employee in the health system you have a duty of confidentiality regarding patients' health information under the Health Act and you are also covered by the General Data Protection Regulation (GDPR) because health information is a special, sensitive category of personal data. In practice this means you only access or share information you have a professional need to know, you never discuss patients outside the proper framework, and data must be stored so unauthorised persons cannot access it.
§Why it matters for you as an assistant
Good documentation is not bureaucracy for bureaucracy's sake. It ensures that the next health professional who sees the patient can rely on the result without guessing, and it protects both the patient and you if there are later questions about what was done and how.
“An examination not properly documented is in practice not performed.”