Decree No. 385 / 2006 Coll.
Order on medical documentation
Valid
Effective from 01.04.2007
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385
DECLARATION
of 21 July 2006
on health documentation
According to Section 67b (19) of Act No. 20 / 1966 Coll., on the Care of People, as amended by Act No. 285 / 2002 Coll. and Act No. 225 / 2006 Coll., ("the Act '), the Ministry of Health provides:
(1) The medical documentation always contains:
(a) the name of the medical establishment, its registered office or place of business, the identification number, if assigned, the name of the department or similar part, where the medical establishment is so divided (hereinafter referred to as "the department of the medical establishment"), and the telephone number of the medical establishment;
(b) the name or, where appropriate, the name, surname, patient's birth number (1), if not allocated, date of birth, address of the patient's permanent residence or other contact address, if different from the address of the permanent residence; if there is a foreigner, the address of the place of residence in the Czech Republic, and if there is no foreign residence,
(c) the insured person's number if this number is not the patient's home number and the health insurance code;
(d) the name and, where applicable, the name, surname, title and signature of the medical professional who made the entry in the medical file;
(e) the name and / or name, surname, address of the place of permanent residence of the person to whom information on the patient's medical condition can be provided, or any other contact address, if different from the address of the place of residence, telephone number or any other contact; if there is a foreigner, the address of the place of residence in the Czech Republic, and if there is no foreign residence; this information shall be provided if the patient informs them,
(f) the date of entry in the health file; in the case of emergency care or visiting services, the medical file shall also record the timing of the provision;
(g) the stamp of the medical establishment, if it is part of the medical file which is transmitted to the patient or under special legislation to another natural or legal person authorised to take over the medical file;
h) in the case of provision of constitutional care date and hour
1. the patient's admission to constitutional care,
2. termination of constitutional care;
3. transfer of the patient to another hospital providing institutional care or transfer of the patient to another department,
4. transfer of the patient to outpatient care,
5. Patient's death,
(i) in the event of refusal of health care by a healthcare institution or, where appropriate, by a healthcare professional or a patient, the date and time of refusal; if there is always a reason for refusal to provide health care to a healthcare institution or healthcare professional; if the patient is refused health care, his written statement of such refusal or, where applicable, a record thereof; if the patient refuses to sign the declaration, the record shall include a written statement by the witness that the patient refuses to provide health care;
(j) information on the relevant circumstances relating to the patient's medical condition, in particular information from the family, personal, epidemiological, social and occupational history;
(k) information on the current state of health, unless otherwise specified.
(2) The medical documentation further contains:
(a) a diagnostic balance sheet and a proposal for a further diagnostic procedure if the patient's medical condition so requires;
(b) the expected final diagnosis, the proposal for further treatment and information on the course of treatment;
(c) a record of the extent of healthcare provided or requested;
(d) record of:
1. the prescription of medicinal products, food for special medical purposes or medical devices;
2. administration of medicinal products or food for special medical purposes to a patient in a healthcare facility, including the amount administered, in the case of a transfusion product clearly identifying the code; the date and signature of the healthcare professional who submitted the medicinal or transfusion product or food for special medical purposes,
3. Equipment of the patient with medicinal products, food for special medical purposes including quantity of medical equipment,
4. medical equipment for the patient;
(e) a record of the issuing of a health transport order;
(f) records of nursing care, description and course of treatment, recommendations for further nursing procedures;
(g) a record of vaccination, including the name of the vaccine and the batch number;
(h) the written consent of the patient or his legal representative to the provision of an investigative, medical or other medical exercise (hereinafter referred to as "medical performance"), where the obligation of written consent is provided for in a specific legal provision (1a), or where, taking into account the nature of the medical performance, consent has been requested by the medical institution in writing;
(i) a record of the patient's consent to provide information on his medical status (2);
(j) a record of the use of restrictive measures against the patient and of the notification to the court;
(k) copies of the information transmitted on the patient in paper form and, where appropriate, a record of their transmission and copies of the opinions;
(l) a record of inspection of the patient-led medical file (3), indicating when, by whom and to what extent the inspection took place; the record shall not be made in the event of consultation by a healthcare professional in connection with the provision of healthcare;
(m) a record of the recognition and termination of temporary incapacity for work and of the commencement of the treatment of a member of the family and their duration; a record of the cessation of temporary incapacity for work shall be made by the medical institution which kept the patient in the register of work of the incompetent citizens before the cessation of work; if the patient has been transferred to another medical establishment in the course of temporary incapacity, the medical file shall also include a record of the date of transfer or takeover;
(n) the records of the doctor of the social security institution relating to the control of the assessment of temporary incapacity for work;
(o) records of other relevant circumstances relating to the patient's medical condition that have been identified in connection with the provision of healthcare.
The patient's medical documentation includes:
(a) the results of the examinations, including graphic, audiovisual, digital or other similar records thereof;
(b) written information on the findings of the patient's health status, course and termination of treatment or recommendations and proposals for additional healthcare to be provided by healthcare institutions in order to ensure the continuity of patient care (4);
(c) in the case of primary health care, written information on the history of the state of health transmitted by the previous initial medical practitioner (5);
(d) in the case of bed care, special outpatient care in stationary 6), or in the case of a patient placed in a healthcare facility for reasons other than health reasons 7),
1. a record of the current state of health as assessed by the patient and a targeted objective finding;
2. a summary of the information (epicriosis) on the course of the examination and treatment and a plan for the follow-up if the duration of institutional care is longer than 7 days;
3. written information of the physician who recommended the hospital's bed care or special outpatient care,
(e) in the case of racing preventive care, data on the content and conditions of work for which the worker's health status is monitored, including data on the inclusion of individual factors of the working environment in the relevant category8) and written information on the state of health or its development since the last medical preventive examination, transmitted by the registered primary health care doctor, if this information is not included in the documentation (9);
(f) records of investigative, therapeutic or administrative performance carried out for the purposes of specific legislation10), including patient health records, and copies of reports, information and data transmitted under such specific legislation;
(g) the recording of information and data necessary for its provision to the National Health Information System.
(1) Each health file shall bear the name and / or the name, surname and birth number of the patient, the date of birth, if no birth number is assigned, the name of the health care establishment or, where applicable, the name of the department of the medical establishment.
(2) The components of the health file listed in Annex 1 to this Decree, which are separate parts thereof, shall always contain the data set out in that Annex, with the application of the provisions of § 1 (1) (a) to (d), (f) and (g) to be applied when recording data and information in separate parts of the health file.
(1) The medical documentation of the emergency care services includes:
(a) an audible record of the call (s) for health care;
(b) the operator's record or log of the operational centre;
(c) a copy of the exit record;
(d) identification and sorting card,
(e) a record of patient mass redeployment.
(2) A daily record book is included in the medical documentation of the first aid medical services.
(1) Entry into the health file shall be carried out by a health professional without delay after any of the facts referred to in § 1 or § 2 have occurred.
(2) The patient's health record referred to in § 2 (d) (1) is supplemented by information on the patient's current state of health at least once every 24 hours; in the event of a substantial change in the patient's health, the alert shall be completed without delay.
(1) The disposal of the medical documentation in the shredder's proceedings shall be ensured by the medical establishment which maintains it, in accordance with the shredder's order set out in Annex 2 to this Decree. This shall apply mutatis mutandis to an administrative authority which has taken over the medical documentation under the law or to the founder of an repealed state health establishment which has not transferred the rights and obligations of that establishment to another medical establishment established by it (hereinafter the "shredding administration ') 11.
(2) The medical documentation shall be kept for a period of 5 years and shall be marked with the shredder "S ', unless otherwise specified in a separate legislation or in Annex 3 to this Decree.
(3) The storage period for a patient-led medical file by one medical institution begins to run on 1 January of the following calendar year after the date on which the event referred to in Annex 3 to this Regulation occurred or the last entry in the patient's medical file was made.
(4) Where the medical file or parts thereof conducted on a patient by its inclusion or material content are subject to several periods for its preservation in accordance with Annex 3 to this Decree, the retention period and the shredder mark shall be determined according to the longest period.
Health documentation kept before 1 April 2007 shall be covered by the shredder schedule and the shredder plan set out in Annexes 2 and 3. If the shredder period specified in Paragraph 6 has expired for this medical file before 1 April 2007 and the shredder procedure has not been carried out or initiated, this procedure may be initiated on 1 July 2008.
This Decree shall take effect on 1 April 2007.
Minister:
MUDr. Rath v. r.
Příloha č. 1
Annex No 1 to Decree No 385 / 2006 Coll.
MINIMUM STATEMENT OF OWN HEALTH DOCUMENTATION
1. INFORMATION FROM THE HEALTH DOCUMENTATION BY THE HEALTH HEALTH HEALTH HEALTH HEALTH HEALTH HEALTH DOCUMENT (DRAFT)
Information from the medical file shall include:
(a) basic historical data, supplemented by the data necessary for the purpose for which the information is issued;
(b) information on the patient's recent medical condition and breakdown of medicinal products used by him, special medical food and medical devices used;
(c) diagnostic summary,
(d) a brief assessment of the patient's state of health, including responses to treatment and dynamics of the development of the results of laboratory and other auxiliary examinations;
(e) other relevant information including information from the assessment.
2. REQUEST FOR OTHER HEALTH
Information to request further healthcare (specialized, special and constitutional) contains
(a) the required care and its justification;
(b) data on the last established state of health, including the results of laboratory and other auxiliary examinations;
(c) data on treatment to date and patient response;
(d) differential diagnostic balance sheet,
(e) a brief assessment of the history data if related to follow-up healthcare.
3. INFORMATION ON THE INVESTIGATION (DOCTOR REPORT)
Information on the examination carried out shall include:
(a) data on the state of health established, including the results of laboratory and other tests;
(b) data on treatment to date and patient response;
(c) recommendations for further provision of health care, including recommendations for assessment;
(d) the reason for refusal of health care or non-acceptance under special legislation11a) where such refusal or non-acceptance has taken place.
4. INFORMATION ON THE PRESENTATION OF THE CONSTITUTION OF THE CONSTITUTION (PRESENTATION REPORT)
A. Information on release from constitutional care includes
(a) a brief indication of the history, current illness,
(b) the duration and course of constitutional care, reflecting why he was hospitalized and what was the result of diagnostic efforts, treatment and treatment;
(c) main diagnosis, secondary diagnosis,
(d) a record of the current treatment, including the indication of medicinal products, food for special medical purposes and medical devices and the results of the examinations carried out;
(e) recommendations for the provision of the necessary health care, including nursing care and recommendations for medicinal products, food for special medical purposes and their dosage and recommendations for medical devices intended for the health care facility, which will provide further health care, and recommendations for assessment.
B. Preliminary information on release from constitutional care (preliminary discharge report) contains:
(a) basic information on the course of hospitalisation in a hospital providing institutional care,
(b) main diagnosis, secondary diagnosis,
(c) a brief record of the treatment to date, including the indication of medicinal products, foods for special medical purposes and medical devices with which the patient leaves the medical institution;
(d) recommendations for further medical care.
5. WRITTEN CONFORMITY WITH HEALTH PERFORMANCE
A. Written consent shall include:
1. data on the purpose, nature, expected benefit, consequences and potential risks of health performance;
2. a lesson on whether the planned health performance has an alternative and the patient has the option to choose one of the alternatives, unless specific legislation excludes this right;
3. data on possible limitations in the normal way of life and in working capacity after the performance of the health performance concerned may be assumed; in the event of a possible or expected change in health status, also data on changes in medical fitness;
4. data on the therapeutic regime and the preventive measures that are appropriate, on the performance of health checks;
5. the patient's statement that the information and guidance provided for in points 1 to 4 has been communicated and explained to him by the health care professional that he understood them and that he had the opportunity to ask the supplementary questions that he had answered by the health care professional,
6. Date and signature of the patient and health care professional who provided the patient with the data and lessons; If the patient is unable to sign, the record shall be recorded in the name, where appropriate, the name, surname and signature of the witness present in the consent speech and the reasons for which the patient was unable to sign shall be given and the manner in which the patient showed his will.
B. If there is a minor patient, a patient deprived of legal capacity or a patient with limited legal capacity, it must be agreed in writing that the relevant data have been provided to the patient's legal representative and to the extent and form of the patient; the legal representative shall sign the written consent in such a case. If the legal representative refuses to sign the written consent, the name, name, surname and signature of the witness present in the refusal shall be indicated and the reasons for which the legal representative has not signed.
C. Parts A and B of this Annex shall apply mutatis mutandis to the withdrawal of written consent.
6. DECLARATION OF HEALTH REFUSED
A. The declaration and, where applicable, the alert referred to in Article 1 (1) (i) shall include:
1. an indication of the patient's medical condition and required medical performance;
2. an indication of the possible consequences of rejection of the necessary health performance for the patient's health,
3. a record of the patient's observations that the data referred to in points 1 and 2 have been communicated to him by the health care professional and explained that he understood them and that he had the opportunity to ask the supplementary questions that he had answered by the health care professional,
4. a written statement by the patient or, where appropriate, a record of such statement that, despite the explanation provided, he refuses the necessary medical performance;
5th place, date, hour and patient signature,
6. signature of the healthcare professional who provided the patient with the information,
7. If the patient is unable to sign or refuse to sign a statement in respect of his health, the record shall be provided on behalf of, or by the name, surname and signature of the witness who has been present with the refusal and the reasons for which the patient has not signed up shall be indicated and the manner in which he has shown his will.
B. If there is a minor patient, a patient deprived of legal capacity or a patient with limited legal capacity, the declaration of refusal of health performance shall indicate that the relevant information has been provided to the patient's legal representative and to the appropriate extent and form to the patient; the legal representative shall sign a declaration or, where appropriate, a record of refusal of health performance. If the legal representative refuses to sign the declaration or, where appropriate, the record shall be accompanied by the name, name, surname and signature of the witness present in the refusal and the reasons for which the legal representative has not signed.
7. ALERT OF CONFORMITY WITH THE PROVISION OF INFORMATION
A record of the consent of the patient or legal representative with the provision of information on the patient's health
(a) identification of the persons to whom the information may be disclosed, including the extent of the information;
(b) the location, date and signature of the patient or legal representative and the signature of the medical officer who processed the alert; If the patient cannot sign for his or her condition, the record shall be signed by another health professional and the reasons for which the patient did not sign shall be indicated and the manner in which he or she showed his or her will.
8.
A. The medical evaluation always includes
(a) identification data
1. persons under consideration within the scope of the name, or names, surnames, date of birth,
2. the medical institution on whose behalf the medical assessment was issued by the assessor, to the extent that the name of the medical establishment was given, the identification number, if assigned, the address of the place of residence or place of business of the medical establishment, the stamp of the medical establishment,
3. the doctor who issued the assessment on behalf of the medical establishment, the name and, where appropriate, the name, surname and signature of the doctor,
(b) the purpose of the assessment;
(c) assessment conclusion,
(d) information on the possibility of submitting a review proposal;
(e) the date of issue of the opinion.
B. Medical evaluation, if issued for the purposes of employment or similar relationships, shall also include:
(a) employer identification data,
1. the business company or the name and address of the registered office of the entrepreneur or the organisational body of a foreign person in the territory of the Czech Republic, the identification number, if assigned, if the employer is a legal person,
2. the address of the place of business, the name or, where applicable, the name, surname, address of the place of permanent residence or the address of the place of temporary residence in the territory of the Czech Republic over 90 days or the address of the place of permanent residence of a stranger in the territory of the Czech Republic or abroad, if the employer is a natural person,
3. the name, registered office and identification number of the organisational body of the State or region or municipality, if the employer is a State, a county or a municipality;
(b) the details of the work classification of the person under assessment, the type of work, the labour regime and the health and safety risks of the work under which he is carried out and the extent of those risks;
(c) the designation of an occupational disease according to the specific legislation12), as regards the medical assessment of an occupational disease.
C. It must be clear from the assessment conclusion of a medical opinion issued for the purpose of assessing medical fitness that the person under assessment
(a) is medically fit;
(b) be disabled on condition; medical fitness with a condition means, for example, the use of the necessary medical device by the person under consideration or any other restriction of the person under consideration to compensate for its health restrictions; This condition shall always be defined in the opinion;
(c) is disabled; or
(d) have ceased long-term medical fitness.
9. DOCUMENTATION OF HEALTH SAFETY SERVICES
The medical emergency services documentation shall consist of a set of documents and records relating to a particular patient or action, including audio recordings (records) of the medical operating centre with time data.
A. The operator's or operational centre's log record shall include:
(a) date,
(b) the serial number of the call for exit;
(c) reporting time;
(d) the patient's personal data, to the extent that the name, surname and date of birth can be ascertained and the data needed to determine the place of intervention;
(e) the telephone number or any other indication of the possibility of connection at the caller, if this information can be ascertained;
(f) personal data of the operator who has taken up the call for departure, to the extent provided for in Article 1 (1) (d);
(g) time of transmission of the call for exit to the medical emergency services group;
(h) arrival time, place of intervention and start time of intervention;
(i) the time and place of transfer of the patient to the medical institution, including the identification data of the receiving medical establishment or the time and place of exit, if the patient has not been transferred to the medical establishment;
(j) personal data of healthcare professionals providing health care to the extent provided for in Section 1 (1) (d).
B. The exit record shall include:
(a) date,
(b) reporting time;
(c) the serial number of the call for exit;
(d) the patient's personal data, within the scope of § 1 (1) (b) and (c), but at least the name and, where applicable, the name, surname and date of birth, if such data can be ascertained,
(e) the time of departure and arrival of the medical emergency services group, a brief description of the clinical condition,
(f) a work diagnosis,
(g) a description of the healthcare provided;
(h) the time and place of transfer of the patient to the medical institution, including the identification data of the receiving medical establishment or the time and place of exit, if the patient has not been transferred to the medical establishment;
(i) personal data and the signature of the intervention manager; personal data shall be provided to the extent set out in Section 1 (1) (d).
C. Identification and sorting card contains:
(a) the unique patient registration number (combination of the letter identifying the region and the serial number of the card);
(b) the degree of urgency of the patient's treatment;
(c) the patient's sorting time;
(d) a work diagnosis;
(e) the time at which the patient is transferred to the removal device;
(f) the type of transport following the composition of the exit group under the special legislature12a);
(g) vital function status (GCS conscious status, blood pressure, pulse and respiratory frequency) and graphically displayed injury localization,
(h) the record of treatment - the medicinal products administered and, where appropriate, the decontamination,
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Regulation Information
| Citation | Decree No. 385 / 2006 Coll., on Health Documentation |
|---|---|
| Regulation Type | - |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 01.08.2006 |
|---|---|
| Effective from | 01.04.2007 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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