The information card from the hospital treatment is actually an individual medical documentation of the patient, and the information it contains is invaluable for doctors who will treat us in the future. That is why it is worth keeping even "historical" records - says Rafał Janiszewski, owner of the Advisory Office providing services in the field of he althcare organization for medical entities and patients' rights.
Anna Tłustochowicz: What is a discharge from hospital?
Rafał Janiszewski:Information card on hospital treatment, which the patient should receive on the day of hospital treatment completion, in accordance with applicable regulations.
And for which patients have to wait a long time.
Sometimes yes, sometimes no.
Mostly yes!
If we wait, it is not because doctors ignore us, but because often all the results of our tests arecollected until the last minute and all activitiesthat were performed on us are described during the entire stay in the hospital.
The information card - commonly known as an excerpt - must contain all of this information.
They will bealso identified by special statistical codes , indicating the underlying disease and comorbidities that the doctors de alt with during our treatment: from the day of admission to the day of discharge from the hospital.
Diseases are only described by codes?
Not only. Also.
But sometimes only in Latin.
That's right. The use of Latin names by doctors is a practice derived from medical science. As a general rule, the information sheet may contain Latin words, but they should function in parallel with names in Polish.If this is not the case, it is because it is often the only one a way to precisely identify certain medical conditions.
They don't have a Polish name?
They are sometimes untranslatable, yes. Hence, it may happen that the main or comorbid medical condition will only be described in Latin. Let's go further:on the information card we will find information about all medications that were given to us during hospitalization . We will learn not onlywhat were the medicinal products, but also what form they were in and what their dosage was. The information about the course of treatment will also includeall diagnostic and treatment procedures.If, for example, we had an operation, the list includes not only information about the operation, but also a detailed description of the type and the course of the procedure and related activities, for example anesthesia.
What is all this for? Why such great accuracy?
First of all, because it isan obligation resulting from the Acts on Patient Rights and Patient Ombudsman : we must receive detailed information about the course of treatment and recommendations, and the carrier of this knowledge is just the information card. And secondly, because both the patient and the doctors who will treat him in the future - it is simply very necessary.
So all hospital records should be kept? Even those from a few or a dozen years ago?
Oh, indisputably yes! Each discharge is, in fact, nothing more thanindividual medical records of the patient , which the patient later uses while continuing the treatment. He presents an information card, or information cards from subsequent hospitalizations, to doctors so that they can find out what he was ill with, how he was treated, and what medications he was taking.A very important part of the extract is the so-called epicrisis.
Epicrisis, i.e. a brief description of a patient's case with a description of his diagnosis and treatment during his stay in the hospital.
This part of the information sheet is no longer in the form of code and statistics, butdescriptive and is mainly aimed at other doctorswho will be treating us in the future.
The excerpt also includes recommendations.
Yes. And they can and very often are divided into two groups:medical and nursing recommendations . In the former, doctors indicate where and how the treatment is to be continued, i.e. the patient will find out that in three weeks he is to report for a check-up at the clinic or continue treatment with a specialist, or that he will have another hospitalization in some time. Medical recommendations also includeinformation on the dosage of prescribed medications and adviceon how we should possibly change our lifestyle. These are all very important matters and we should always read and apply this information carefully - for our own sake. On the other hand,nursing recommendations, where entering information into the cards has become a good practice , apply to all kinds ofcare or hygiene treatments that were not provided directly by doctors. Nurses look at he alth problems quite broadly, and in their recommendations they include very important issues, such as how often and how we should change dressings.
In the excerpt we will also find information about a possible L 4, right?
That's right. If, after the hospitalization period, we are temporarily unable to work and receive a sick leave, then the information sheet will containannotation from when to when L 4is valid. Please also note, by whom is the information card signed?
By the attending physician?
Very often. The information card is signed by the doctor who discharges us from the hospital. As a rule, it is our attending physician and the doctor in charge of the department, i.e. the head of the department.The names of both doctors are also important information for patients , because they very often want to re-contact the specialists who guided them during hospitalization. They want this contact to "show up" and consult them. For many patients, the knowledge of the names of the attending physician and the head physician is very important.
I would also like to point outhow important is the information card for those patients diagnosed with chronic diseases . Make it diabetes. The diagnosis of diabetes is of course included in the information sheet, and thanks to this, the primary care physician has the opportunity to continue the treatment of this patient and, consequently, to issue prescriptions with a flat-rate surcharge for drugs used in chronic diseases.
During hospitalization, a neoplastic disease could also be detected.
And in this case, remember that thenhistopathological examinations are performed very often . When leaving the hospital, the patient receives - in the information sheet - a recommendation to report the test result in a few weeks and to establish a further treatment plan. You absolutely must comply with this! Often times, the hospital will ask you to confirm in writing that you have received the result. It is about responsibility for further treatment: if the cancer is confirmed, the hospital asks us to sign with the name and surname under such information and recommendations for further treatment. Asome hospitals, as a rule, require a signature for each discharge.In both situations - we should follow the doctor's request.
Finally, please, let's come back to the threadstoring discharge records from the hospital. Do we really need those from ten years ago as well?
Of course it is! As I mentioned - the excerpt is an individual medical documentation.
External documentation, i.e. for the patient and his future doctor or doctors.
Even if we come to a specialist or even a primary care physician after these ten years, bringing an information card from the hospital treatment with us - even from many years ago - will give him a picture of what we were ill with, how we were treated, what medications we took, were we allergic to them and how we reacted to them: whether they worked or not. This is very valuable information!
Now you have made all the readers who have been throwing excerpts very upset.
Maybe some people will change their approach from now on? I always recommend not only to keep all the information cards, but also to make the information card available to your GPat your next visit after leaving the hospital . I believe that it is very important for our GP to read this information, write down some of it, or even copy it and add it to our documentation, which he keeps.
The information card from the hospital treatment is really a huge collection of knowledge about the patient!
Our test results, how we react to drugs, our allergies, all illnesses, treatments, operations: for every doctor who will treat us later, these areinformation that is simply priceless. And most of all for us they will be invaluable whenever, for whatever reason, we seek medical help. Sudden illness? Accident? Loss of consciousness? Our relatives take our information card from the last hospitalization, go with it to the hospital and show them to the doctors, who already know which medicine we are allergic to and which is great for us.It helps you save time and can be a great help in saving lives!
So: we read the extracts carefully, keep them at home and let the family know where to find them.
That's right.We even keep "historical" information cards , because even those from years ago are of great importance.
Rafał Janiszewski, owner of the Advisory Office providing services in the field of he althcare organization to he althcare entities
Speaker, organizer of many trainings and conferences on he alth protection and patient rights. In the years 1998-1999 an employee of the Office of the Government Plenipotentiary forIntroducing the General He alth Insurance. Author of over 20 books on he althcare organization and he alth care financing standards. In 2005-2007, he was an expert of the Presidium of the Parliamentary He alth Committee, as an advisor on he alth services. Co-author of the general study as part of the Pharmaceutical Pricing and Reimbursement project for the European He alth Commission.
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