I denna rättshistoriska översikt beskrivs hur skyldigheten att föra patientjournal har växt fram i svensk hälso- och sjukvårdsreglering. Från att inledningsvis ha varit ett administrativt åliggande för sjukhusen, kom olika läkarspecialiteter att allteftersom bli skyldiga att dokumentera. Länge rörde skyldigheten enbart patientadministration, medan dokumentation av individuella patienters vård och behandling betraktades som en fråga som den enskilda läkaren själv rådde över. Under andra halvan av 1900-talet infördes dokumentationsskyldigheter även för andra yrkesgrupper inom hälso- och sjukvården, men först med 1985 års patientjournallag konstruerades skyldigheten på ett unisont sätt för samtlig hälso- och sjukvårdspersonal. Med 1985 års patientjournallag kom även patientens rättigheter att beaktas vid regleringen av patientjournalen.
This historic overview describes how the obligation to keep a patient record emerged as a result of regulation of health and medical care. From initially having been an administrative obligation for the hospitals, various medical specialities were gradually included in the obligation. For a long time, the obligation concerned only the administration of the medical services, while documentation of individual patients’ care and treatment was regarded as something the individual doctor disposed over. From the mid-1900s, obli-gations to keep patient records were also introduced for other occupational groups in the health and medical care sector, but the obligation was not con-structed in a unified manner for all healthcare personnel until the introduction of 1985 Act on Patient Journals. This act also introduced the rights of the patient as a relevant consideration
This dissertation fills part of the existing knowledge gap regarding the relationship between the legal obligation to document medical care and treatment on the one hand, and the professional practice, conditions and identities of professionals on the other. Three basic questions serve as points of departure: what are the origins of the obligation to document medical care and treatment? How is the relationship between the patient and the professions affected by the obligation? How does the obligation affect professional identities? The dissertation consists of five sub-projects performed with a combined legal and social constructivist approach. Two relate to the historical emergence of an obligation for physicians and other professions to document medical care and treatment in Swedish healthcare. One concerns how standardized forms of documentation affect the patient’s legal position and two are built upon the fact that the legal obligation for licensed psychotherapists within municipal family counselling to document their interventions has lapsed, even though the legislation clearly prescribes such an obligation. The results suggest that the form of governance known as New PublicManagement has been preceded by regulations regarding the obligation ofdocumentation, which are clearly intended to meet financial and organizationalgoals. This may have contributed to the fact that Sweden is one of the countrieswhere New Public Management has influenced the public administration the most.The thesis concludes that the effects of the regulations regarding of the obligationto document medical care and treatment, and the forms of implementation ofthe obligation, are of crucial importance for a patient’s legal position. Furtherresearch is needed in order to highlight and better understand the processes thatare at play when the regulations are enforced and implemented amongst healthcare professionals.