Abstract
WHAT IS THE IMPORTANCE OF DOCUMENTATION IN HEALTH

Theoretical background: Way to document health care is not defined by any legal act. Therefore in health documentation is managed content. It also documents health records are not insured against theft or loss. Methods: Based on the analysis of legal acts in the field of health documentation, compilation of findings and observation practices were devised arguments. Results: Keeping health records, nor the processing of documents in this collection does not fall, does not constitute legal certainty for patients and providers. In practice, in the health sector faced with the absence of documentation, due to undefined responsibilities documenting all findings and implemented procedures of health workers, as a result of a legal vacuum in the field of documenting and protecting the health of documents. Discussion and Conclusion: Documenting health care is increasingly important for the exercise of the rights of the individual artist and the legal and redress procedures; both in terms of evidence supplied explanatory duty, as the findings of evidence and the procedures carried out health treatment. Therefore, especially judicial experts note the great importance of sound recording of all statements patient's will, finding the facts and carried out health treatment. The absence of the record does not constitute the legal basis of evidence and that it was some health treatment (intervention) is carried out. The absence of documentation prevents the exercise of rights of patient and the control verification of the adequacy of procedures. Patients’ Rights Act by giving the patient the right to acquaint themselves with their health records, but since no law for health professionals can retrieve targeted and consistent documentation of procedures, as well as the protection of individual documents, this right remains purely fictitious. Law on health documentation is therefore necessary to upload the contractor the duty and guidelines for filing and storag