[Clinical history: its use and confidentiality]

Prior to the entry in forces of Law 41/2002, the clinical history was regulated by internal functioning guidelines of the Sites and by the Ethics and Medical Deontology Code. The new law establishes the concept, composition, content, conservation and custody of the clinical history. It also foresees the establishment of guidelines that facilitate the coordination between the different regional communities in order to homogenize this documentation and make it compatible. The law also regulates access, use, and control of the clinical history and the documentation contained in it as well as its limitations and role of the professionals in establishing them. On the other hand, it determines the obligation of confidentiality on the data contained in it and who it affects. The clinical history is an obligation and right of the professional since it not only facilitates the care but also is the most important probative element in cases of claims of responsibility, having a clarifying function.