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The content of the medical file
1. What is it?
The content of the medical file
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Medical information relating to the patient, whether in private practice, in a clinic or in a hospital, is recorded and kept in a file, commonly called the "medical file".
Medical information relating to the patient, whether in private practice, in a clinic or in a hospital, is recorded and kept in a file, commonly called the "medical file".
This obligation dates from the hospital reform of 1970 for hospitals and the year 1995 for private doctors.
This medical file therefore brings together all the information which is formalized and which “contributed to the development and monitoring of diagnosis and treatment or preventive action or was the subject of written exchanges between healthcare professionals. health, in particular the results of examinations, consultation, intervention, exploration or hospitalization reports, treatment protocols and prescriptions implemented, monitoring sheets, correspondence between health professionals, with the exception of information stating that they were collected from third parties not involved in the therapeutic care or concerning such a third party ”.1
We can remember that a priori, must be in the patient's medical file:
- Exam results
- Reports of consultation, intervention, exploration or hospitalization
- The protocols and therapeutic prescriptions implemented
- Monitoring sheets
- Correspondence between health professionals
All this medical or paramedical information in the file, as long as it concerns the patient and not a third party, is part of this medical file, in the legal sense of the term, and must therefore be brought to his attention if he so requests ( see sheet "communication of the medical file).
The doctor's "personal notes" may possibly escape this communication if it is established that they are only documents "personal" to the doctor, and that they have not been used and cannot be used for the preparation. and monitoring diagnosis and treatment, or preventive action.
The question of the "support" of this medical information has arisen more recently, with the advent of the "Personal Medical Record" (or DMP), which is currently being deployed.2
The legislator has provided that "health professionals or health establishments or the person concerned may deposit personal health data, collected or produced during prevention, diagnostic or treatment activities, with persons physical or legal approved for this purpose. This data hosting, whatever the medium, paper or computer, can only take place with the express consent of the person concerned. "3
Obviously, it is more the hypothesis of outsourced computer storage that poses a problem, the concern above all about the confidentiality of the data stored in this way.
Legal and regulatory provisions have therefore come to frame this activity, and will be further strengthened during the second phase of DMP development, a priori from 2014.
Each insured person (including over 16 years of age) will eventually be able to benefit from a Personal Medical File, which is a dematerialized file, that is to say computerized, and hosted by an approved health data host. .4
The DMP is intended to contain all the information enabling the monitoring of procedures and care services.
Each health professional, working in town or in a health establishment, will report in the DMP, during each procedure or consultation, the diagnostic and therapeutic elements necessary for the coordination of care.
The DMP will also include a component specifically intended for prevention.
The inherently confidential nature of the information mentioned in the DMP raises the question of rights of access to it.
In general, access to the DMP will be systematically subject to the prior acceptance of the patient.
In an emergency, and when the patient is unable to express his or her wishes, the caregivers and the regulator of the SAMU - center 15 will be able to have access to the information contained in the DMP unless the patient has previously made known his denial of such access.
Moreover, in the event of death, the beneficiaries of the deceased person will also have access to the information of his DMP, always subject to the limit of a possible refusal made by the person during his lifetime.
Finally, and to avoid any drift, in deho
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