Medical documentation - medical history, medical examination results - is kept in every clinic and hospital where you undergo treatment. Remember - you have the right to access your medical records kept in he alth care institutions!
Each he alth care facility ( hospital ,clinicetc.) and private surgery where you are treated or treated must conduct yourmedical records . The general rules for keeping such records in various institutions are similar, but they differ as to the time of their storage.
The documentation is kept in writing, possibly also in electronic form. The documentation must contain your data and be legible; each entry must be dated and signed by the doctor. No entry can be deleted. The documentation must be protected against damage and confidentiality must be guaranteed.
Documentation is divided into internal, including your he alth and illness history, test results, etc., and external, including referrals to a hospital or other he althcare facility, for diagnostic tests, etc.
In private offices, the documentation is kept for a period of 10 years from the last entry. Only in the event of death as a result of bodily injury or poisoning, it is kept for 30 years.
Record-keeping in he althcare facilities is similar to that in private practices, but there are some differences. Documentation is divided into individual, relating to individual patients, and collective, covering all patients using the he alth services of the institution. Collective documentation is kept in the form of books, registers, forms or files.
If you have been refused admission to the hospital, it must be recorded in the refusal book with the date, information about the diagnosis of the disease, the results of the tests performed, the reasons for refusing you to the hospital and the medical treatment. The entry must contain your data and the doctor's.
Archival documentation is kept for the period of 20 years, individual internal documentation in the case of death as a result of bodily injury or poisoning - for the period of 30 years.
X-rays, referrals for examinations and doctors' orders are stored for the period of 10years. After these periods, the documentation should be destroyed so that the patient cannot be identified.
Medical records of occupational medicine are kept for 20 years. If you are exposed to carcinogens or mutagens, this period is 40 years after the cessation of that exposure.
If the plant or occupational medicine office has ceased its activity, medical documentation is submitted to the appropriate voivodeship occupational medicine center.
At your or an authorized person's request, the doctor must provide you with your documentation or prepare an extract from it. However, you must pay for the cost of making the copy.
Your rights regarding medical records:
- The doctor is obliged to explain to you in an accessible and understandable way the content of the entries contained in the documentation
- Doctors or medical staff must not withhold test results, hospital records or patient records from you.
- Obstructing Ci accessing medical records or making copies of them is a violation of the provision which imposes an obligation on he althcare institutions to provide access to medical records.
- Employees of he alth care facilities are obliged to maintain professional secrecy under the pain of civil liability. Disclosing and unjustified disclosure of personal medical data may result in lawsuits and claims for damages.
- The He althcare Institution may share your medical records with another facility or a natural person exercising a medical profession, if this documentation is necessary to ensure the continuity of he alth services, and you consent to it.
The he althcare facility may also make medical documentation available to:
• competent state authorities and medical self-government bodies to the extent necessary to perform control and supervision,
• the Minister of He alth, courts and prosecutors, courts and professional liability ombudsmen, in connection with the proceedings,
• authorities and institutions authorized under separate acts, if the examination was conducted at their request,
• pension authorities, insurance companies and teams for deciding on the degree of disability in connection with the proceedings conducted by them,
• registers of medical services, to the extent necessary to keep registers (in accordance with the Act of August 30, 1991 on he alth care establishments). • a university or research and development unit, for research purposes, without disclosing your name or otherdata enabling the identification of the person to whom the documentation relates (in accordance with the above-mentioned act).
We can distinguish two types of validity of medical examinations - resulting from the provisions of occupational medicine and the clinical condition of the patient. The validity of examinations performed before an occupational medicine visit is determined by specific regulations - the dates vary depending on the position or function performed by a given person. For example, pilots have their blood pressure checked each time they start their work. From the point of view of he alth assessment, the decisive factor is whether the tests were performed on a he althy or sick person. In the case of a he althy person, the expiry date may be longer, in the case of a sick person it is shorter. The final decision as to whether the examination is "valid" rests with the doctor.
NFZ, Ministry of He alth