Medical Documentation in the Endoscopy Department: The Necessity of Record-Keeping and Regulatory Framework
https://doi.org/10.31146/2415-7813-endo-67-3-93-100
Abstract
Goal: to demonstrate the necessity and importance of maintaining specialized medical documentation in the endoscopy department to ensure the safety of patients and medical staff, reduce the risk of healthcare-associated infections (HAIs), control the quality of medical services, optimize resources, and comply with the regulatory requirements of the Russian Federation legislation. To examine how systematic and accurate record-keeping contributes to improving the efficiency of the department’s operations and reducing the risk of issues during inspections by regulatory authorities. Materials and methods: the study is based on an analysis of the practice of maintaining medical documentation in the endoscopy department of a medical organization. Various types of registration logs (for procedures, disinfection, consumables accounting, staff training, etc.) and their functional purposes were reviewed. The research methods included systematization of regulatory requirements, comparative analysis of the content of logs, and assessment of their impact on enhancing the safety and quality of medical care.
Keywords
endoscopy department,
medical documentation,
logs,
patient safety,
quality control,
endoscope disinfection,
staff training,
regulatory requirements,
resource management,
occupational safety,
sanitary standards,
legal responsibility
About the Author
A. L. Avdyugina
State Budgetary Healthcare Institution of the Moscow region “Moscow Regional Clinical Tuberculosis Dispensary”; Federal State Educational Establishment of Professional «Medical College»
Russian Federation
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