Medical documentation and electronic medical documentation

The authors presented the characteristics of documentation, including medical documentation. They drew attention to the basic elements that it should contain - data allowing identifi-cation of the entity, the employee providing benefits, numbering entries in chronological order, surname, first name and the pa-tient's PESEL number (mother's PESEL number in the case of a newborn child or number and type of identity document, when the PESEL number has not been assigned), as well as the date of making individual entries. The importance of legal acts obliging each entity to readable and chronological complete data contained in medical records is underlined. The making of entries must take place immediately after providing the patient with the benefit. In addition, every person who makes an entry is required to label it with his or her name. No information contained in the documen-tation can be removed from it. The features of electronic medical records were also discussed. It was emphasized that nowadays it is the whole of documents (made in an electronic version) certi-fied by Profil Zaufany ePUAP (ePUAP Trusted Profile), qualified electronic signature or a free system offered by ZUS