Medical documentation, kept in electronic or paper form, consists of individual and collective documentation.
When speaking and writing about documentation, it is worth remembering:
1) individual documentation - relating to individual patients using he alth services;
2) collective documentation - referring to all patients or specific groups of patients using he alth services.
It is worth noting that the individual documentation includes:
1) individual internal documentation - intended for the needs of the entity providing he alth services
2) external individual documentation - intended for the needs of a patient using he alth services provided by the entity.
Internal individual documentation
In the internal individual documentation an entry is made about the issuance of the external individual documentation or its copies are attached. Each page of the individual documentation kept in paper form is marked with at least the first and last name of the patient. In the case of making a printout from individual documentation kept in electronic form, each page of the printout is marked with at least the first and last name of the patient.
If it is not possible to establish the patient's identity, the documentation is marked with "NN", stating the reason and circumstances preventing the identification. The internal individual documentation includes copies of the documentation presented by the patient or the information contained therein is important for the diagnostic, treatment or nursing process. A document included in the individual internal documentation cannot be removed from it.
The he althcare provider provides medical documentation
1) entities providing he alth services, if this documentation is necessary to ensure the continuity of he alth services;
2) public authorities, the National He alth Fund, bodies of the self-government of medical professions and national and provincial consultants, to the extent necessary for these entities to perform their tasks, in particular control and supervision;
3) disability pension authorities and teams for adjudication of disability, wconnection with the proceedings conducted by them;
4) entities maintaining registers of medical services, to the extent necessary to keep the registers;
5) insurance companies, with the patient's consent;
The entity providing he alth services keeps medical records for a period of 20 years from the end of the calendar year in which the last entry was made, except for:
1) medical records in the event of death of a patient as a result of bodily injury or poisoning, which is stored for a period of 30 years from the end of the calendar year in which the death occurred;
2) X-ray photos stored outside the patient's medical documentation, which are kept for a period of 10 years, counting from the end of the calendar year in which the photo was taken;
3) referrals for examinations or doctor's orders, which are stored for a period of 5 years from the end of the calendar year in which the service being the subject of the referral or order was provided;
4) medical records concerning children under 2 years of age, which are kept for the period of 22 years.
After expiry of the storage periods, the entity providing he alth services destroys the medical documentation in a way that prevents identification of the patient it related to.
After the expiry of the storage periods, the provisions issued pursuant to Art. 5 sec. 2 and 2b of this act.
Then the archival materials are made available to organizational units and citizens (e.g. family members of the person whose medical records have been archived) and for the purposes of science, culture, technology and economy. Providing access to archival materials for the above needs is free of charge.
Legal basis:
Act of 14 July 1983 on the national archival resource and archives (Journal of Laws of 2011, No. 123, item 698 and No. 171, item 1016),
Act of 6 November 2008 on the rights of patients and the Patient's Rights Ombudsman (Journal of Laws of 2012, item 159 as amended)