Patient Medical Records Will Remain Accessible

Often, patients demand to provide them with medical documents without restrictions and immediately, which does not cause enthusiasm on the part of doctors. The latter, too, we can understand-since then it is the doctor who has given the document or its copy “in the wrong hands”who will be responsible for the possible disclosure of medical secrets (and, perhaps, for something worse).

At the same time, the legislation for a very long time lacked norms that would clearly and clearly define the procedure for providing medical documents or copies of them to patients. As a result, medical organizations were forced to develop their own approaches to issuing such documents. All this, of course, did not add to the mutual understanding between doctors and patients.

The Procedure for providing medical documents (their copies) and extracts from them (hereinafter referred to as the Procedure), approved by the Ministry of Health, should have clarified this important issue. Did he succeed in achieving this goal? In my opinion, not quite. Of course, having a single federal act is better than having nothing at all. However, many issues have not been resolved. So, let’s go through some of the controversial places of the new Order.

To begin with, let’s ask the question, and what generally applies to medical documentation? Which document deserves the name of medical, and which does not? Unfortunately, this term is not explained in the federal legislation. Paragraph 1 of the order defines medical documents “as documents reflecting the patient’s health”. All this sounds very vague and ambiguous. In my opinion, the definition of a” medical document ” should be more clearly specified.

Let’s take, for example, the log of surgical interventions. Or an emergency notification of acute poisoning. Are they medical documents? Does the patient have the right to request an extract from them? Based on the definition of a “medical document” proposed in the Order, judgments on this matter may differ significantly. It is very strange why the developers of the Order did not make a clear and exhaustive list of documents that patients can request.

The procedure does not always determine when the patient has the right to demand the original document, and when-not. It should still be noted that paragraph 3 of the Procedure contains a list of cases in which the patient can be issued a copy or statement, even if he initially required the original. However, the trouble is that this list is closed and contains only 12 documents. It includes the medical records of the outpatient and inpatient patient, the medical kata of the child, the history of childbirth, the history of the development of the newborn, the protocol of the pathologic and anatomical autopsy, and some other documents.

But what about medical documents that are not included in the closed List of item 3 of the Order? And this is, for example, an emergency medical service call card, a sanitary-resort card, and many others. Since they were omitted in paragraph 3 of the Order, it turns out … that the patient has the right to request the originals of such documents. But this is absurd! Unfortunately, such forgetfulness of the developers of the Order can turn into numerous slanders (or even lawsuits) of patients. I have bad feelings, especially about the ambulance. Conflict situations in its provision are not uncommon and it is possible that dissatisfied patients, referring to the new Order, will demand the provision of the original call cards.
Throughout the text of the Order, the phrase “a copy of the document or an extract from it”is widely used. Well, let’s assume that we have an unambiguous case when the original is not subject to handover (for example, the document is directly specified in paragraph 3 of the Order). However, who makes the final decision about what will be issued-a copy or an extract? Is it a patient or a doctor? Agree, there is a significant difference between a full copy of the document and an extract from it. In paragraph 2 of the Procedure, it is indicated that the patient’s application for a document is made in a free form. Only the name of the requested document is mandatory. But can the patient in his application insist on receiving a copy of the document, and not an extract? And will the patient then” sue ” the doctor for wanting to get a copy, and the doctor only issued a statement? Unfortunately, the adopted version of the Order does not provide an answer to these important questions.
The Order contains the most important norm (point 7 of the Order), according to which analog or digital images can be attached to documents, copies and extracts: X-rays, fluorograms, photo, film images, microfiche. A useful and correct norm — after all, many of the medical documents without such applications lose most of their value. However, why did the legislator decide to limit himself to images only? Why does the Procedure not provide for audio and video files to be attached to the statements? Recall that audio and video recordings of telemedicine consultations and consultations of doctors are stored for one year (in accordance with paragraphs 58 and 61 of the Procedure for providing Medical Care using telemedicine technologies). It turns out that the Procedure does not provide for the patient to get acquainted with a copy of the telemedicine consultation on his own case, and, moreover, to copy the record of such a consultation. All of this undermines the already fragile trust in telemedicine.

In connection with the previous remark, I would also like to note that it is not clear from the text of the Order whether ECGs, EEGs and similar things are considered “photographic images”. Once again, we face the problem of a closed exhaustive list. According to paragraph 7 of the Procedure, the documents (copies) issued to patients may be accompanied by:
radiographs;
fluorograms;
photo images;
movie images;
microfiche;
digital images on magnetic tapes, CD-and DVD-disks, magnetic-optical disks.

Formally, ECG, EEG, and similar materials are not included in any of these categories, which means that there may be problems with their delivery to the patient (it turns out that the Procedure does not provide for their delivery).
We will continue to consider the long-suffering point 7 of the Order (which provides for the transfer of analog or digital images together with the document). It does not apply to cases of issuing medical documents in the form of an electronic document. The inability to attach a film radiograph to an electronic document is quite understandable. However, what prevents you from attaching a digital image as an attached file to an electronic digital document? Why does the Order forbid this? From our officials, we hear a lot of words about innovation and “digitalization”, but now we are facing the opposite example: the introduction of” top ” unjustified prohibitions that slow down the transfer of medical documents to electronic form.
It is not at all clear from the Order whether it is possible for the patient to receive the image separately from the rest of the documentation. For example, does a patient have the right to ask for only a copy of their radiograph, without requesting a copy of the medical record or an extract from it? Such a “white spot” is a potential source of disputes between doctors and patients.
There are some complaints about the timing of the issuance of documents (copies, extracts). According to paragraph 8 of the Procedure, the deadline for issuing documents to patients who are in hospitals and day hospitals is 1 day. But for all the others-30 days (the standard period under the Federal Law on citizens ‘ appeals). Such norms may lead some of our impressionable citizens to think about discrimination against outpatient patients. I, of course, accept the arguments that inpatient patients usually need more documentation, and it is faster to prepare it on the spot, in the hospital. I admit that the difference in terms between inpatient and outpatient patients is caused by objective reasons and, therefore, is inevitable. But the 30-fold difference in deadlines is still, perhaps, too much.
The rules of procedure related to the issuance of extracts from medical documents did not avoid shortcomings. So, according to point 10 of the Order, the extract from the patient’s medical documentation “is signed by the doctor (paramedic, midwife)”. However, nowhere does it say that the doctor who signs the statement must be the patient’s attending physician. Accordingly, the Procedure leaves us with an unresolved question: can a doctor who is not directly related to the patient personally issue an extract from his medical records? Does the Procedure allow to sign such statements to any of the doctors of the medical organization-even if the patient was not treated by him?

The legal construction described above (“signed by a doctor (paramedic, midwife”) has another drawback. It does not say that the paramedic and midwife can only sign statements when performing the functions of a doctor. The result is a situation where any paramedic of a medical organization can be authorized to draw up and certify with his signature extracts from medical documents. Naturally, this does not have a particularly good effect on the issues of maintaining medical confidentiality. In addition, such a paramedic risks becoming a “scapegoat” for all inconvenient issues related to the content of such statements.

It should be noted that for the registration of copies, the Order just provides for a “responsible medical worker” – one for the entire medical organization. However, the statement is not a copy, and it is more difficult to make a correct statement than to copy the sheet. And the price of an error in the case of an incorrect statement is much higher. Therefore, I still consider it rational to assign the functions of signing an extract from the medical documentation to the patient’s attending physician or the doctor who drew up the document from which the extract is made. To do this, you can replace the words “signed by a doctor (paramedic, midwife)” with “signed by the attending or duty doctor or the doctor who directly drew up the medical document from which the extract is made (as well as by the paramedic or midwife when assigning them the duties of a doctor)”.

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