Related Experiment Video
Updated: Mar 1, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
[Who decides what data should be recorded in the medical history in relation to the biological origin?]
Sergio Gallego Riestra1, Isolina Riaño Galán2
1Servicio de Inspección de Servicios y Centros Sanitarios, Consejería de Sanidad, Principado de Asturias, Oviedo, España.
Abstract:
There is an increasing request by patients or their representatives not to have some data registered in their clinical history or if such data exists to be deleted. Without doubt, this is so because such clinical data is accessed by various professionals who in most cases are not directly involved in caring for such patients. On the other hand, such data is copied and iteratively and unnecessary reproduced in various discharge reports and others forms. The problem arises when such controversial data refer to particularly sensitive clinical aspects such as assisted reproduction techniques, which invades personal and family privacy. Therefore, the question is who determines what data should be recorded in the medical records and according to what criteria should be taken that decision?
Related Concept Videos
Data Collection I
Data Reporting and Recording
Purpose of Health Records II
Data Collection II
Criteria for Causality: Bradford Hill Criteria - II
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:

