What must be in a patient file?

What must be in a patient file?

Such a file contains the collected documents and records of a doctor about a patient. This includes the anamnesis, diagnoses, notes on examinations, examination results, therapeutic measures, operations, findings, explanations and consent and, last but not least, doctor’s letters.

Can I request my documents if I change doctor?

According to 10 para. 2 BOK, the doctor has to allow the patient to inspect the patient’s medical records at his request or to hand over copies of the records against reimbursement of the costs.

Who will get the doctor’s letter?

After inpatient treatment in the hospital or after an examination by a specialist, patients receive a doctor’s letter. After a stay in a clinic, this is also referred to as a discharge letter. The purpose is the same: a doctor gives information to a colleague.

Do you have a right to your x-rays?

In the case of X-ray and ultrasound recordings, the right to inspect, not to surrender, applies because these are the property of the doctor. Your doctor can, however, give you the recordings on loan.

When can a doctor pass on patient data?

Patient data may only be disclosed if legal regulations grant the doctor an obligation or a right to disclosure or the patient has given his express or tacit consent.

Which patient data are subject to data protection?

Patient data are subject to data protection. The information that doctors collect and use about their patients is also fundamentally subject to medical confidentiality and therefore a special duty of confidentiality.

When is a doctor liable to prosecution?

If a doctor violates these regulations, he is liable to prosecution according to § 96 No. 10, 11 AMG. If a person is endangered, injured or killed by the medical measures, the doctor can also be sentenced by a criminal court to a fine or imprisonment for bodily harm or manslaughter.

Who does a doctor have to give information?

As a rule, a doctor can assume that it is in line with the patient’s will to inform the spouse or registered partner to the extent necessary, explains Kaplan. If the doctor has doubts, he can let the family court rule. “That usually happens very quickly,” says Ratzel.

Does a doctor have to maintain confidentiality?

The pledge that is printed at the beginning of the model professional code for doctors working in Germany already takes up medical confidentiality. Every doctor has to keep the “secrets entrusted to him, even after the patient’s death”.

Who can lift medical confidentiality?

The patient can also verbally release his doctor from his duty of confidentiality. The same applies to public or company doctors. They are actually not allowed to reveal more than family doctors. However, if an employee agrees to his patient data being released, the company doctor may pass it on to the boss.

What can the doctor tell the health insurance company?

Contract doctors and psychotherapists are entitled and also obliged to issue medical certificates and to create reports that the health insurance company or the medical service (MDK) need for their statutory tasks (Section 73 (2) No. 9 SGB V).

Who can the health insurance company give information to?

The doctor may only provide information about patient data to private insurers if the patient has given his / her consent for this specific purpose.

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