Doctor's letter

Doctor's letter about cardiac surgery

The doctor's letter is a transfer document for communication between doctors. The terms Epicrisis , discharge letters, discharge letter , patient letter or report of findings imply specific content or applications and are most synonymous to use in part. The doctor's letter is created for the individual treatment case in the treating facility and begins with the admission to the facility and ends with the discharge of the patient from the facility. The doctor's letter gives a summarized overview of the patient's status at discharge, a review of the course of the disease , the therapy initiated , an interpretation of what happened to the course of the disease in a special case, information on the classification of the disease according to ICD , OPS , ICF and, if necessary, also DRG and recommendations for continuation of therapy.

The doctor's letter is a form of information for the referring physician or dentist , the one admitted to a hospital or other medical treatment in the outpatient setting a transfer has caused or for further treatment doctor who takes over the further treatment.

aims

The doctor's letter is intended to clearly document the status upon discharge and to ensure the continuity of treatment for the patient . For this purpose, short handwritten doctor's letters with a few essential data are often first given to the patient to be passed on to the treating doctor on the day of discharge. The detailed doctor's letter is often sent later. Doctor's letters, although often difficult to understand for the patient, can also serve as information for the patient himself. In addition, doctors' letters often serve as the first source of information for assessing hospital treatment by the medical services of the health insurance companies in Germany or doctors of the social insurance and private insurance carriers and regional funds in Austria .

content

The content and scope of a doctor's letter can differ considerably depending on the specialty and, for example, in the case of rehabilitation facilities, also contain information on the social environment. In principle, however, the doctor's letters should be as short and concise as possible.

The doctor's letter is addressed first to the referring doctor. In addition, it can be addressed for information to other physicians involved in the treatment as well as the patient himself.

In addition to personal information about the patient (first and last name, date of birth and home address) and information on the duration of the treatment, a doctor's letter contains a list of the current diagnoses and secondary diagnoses, if possible with the appropriate ICD-10 classification as well as the treatments and important findings, such as tissue examinations .

The reason for the treatment is discussed in the introduction that follows. This current medical history includes complaints and planned examinations.

Usually, the current findings of the physical examination at the time of admission to the hospital are described. Information on the age and gender of the patient, general condition (good / light / moderate / greatly reduced) and nutritional condition (normal / obese / cachectic ), biometric characteristics ( height and weight , body mass index ), state of consciousness (awake / somnolent / soporous / comatose), orientation (time, place, situation, person), vital signs ( pulse rate , blood pressure , body temperature , breathing rate ), inspection of the skin ( jaundice ? cyanosis ? rash ?), auscultation findings of the heart ( heart sounds : pure / split / Additional, pathological heart sounds : systolic , diastolic ), the lungs (vesicular / bronchial / amphoric breathing noises , secondary breathing noises: rattling noises , stridor , wheezing ) as well as the intestinal noises (lively / reduced / "dead silence"), palpation findings of the abdomen (tenderness?) , Liver (enlarged?), Spleen (normally not palpable) and percussion findings of the kidneys (knocking pain in the kidneys ), localization of pain , established edema (sy mmetric / one-sided), the recorded pulse status and reflex status ( muscle reflexes , Babinski reflex ), the mobility of the extremities (arms and legs) according to the neutral-zero method and other examined body parts.

Have further diagnostic measures such as laboratory diagnostics ( hematology , clinical chemistry , serology , bacteriology , virology , etc.), imaging ( sonography , X-ray , CT , MRT , etc.) or functional (e.g. spirometry , ergometry , tilting table examination ) apparatus-based examinations been carried out? , their results are communicated. If surgical interventions have taken place , their progress is shown as a brief summary of the operation report.

In the actual epicrisis , the course of the entire treatment is interpreted and summarized in retrospect.

Information on medication upon discharge serves the doctor in charge of further treatment as a recommendation for further prescription of drugs . According to Section 115c (1) SGB ​​V, the name of the active ingredient and, if applicable, cheaper alternatives must also be specified. If necessary, further recommendations for further treatment, such as antibiosis , stringing , physiotherapy , follow-up examinations , or desired follow-up visits , follow .

In the case of inpatient treatment in a clinic, the doctor's letter is usually signed by the chief physician , the responsible senior physician and the attending ward physician .

shape

Traditionally, treating physicians, specialists and hospitals exchange information on the course of treatment by post.

As an improvement in the interest of a smooth flow of information, a secure and reliable transfer and storage medium is useful, with which doctor's letters can be exchanged and saved quickly. All those involved in the treatment are given systematically restricted access to this information (reading, writing, correcting, signing, generating, adding) according to their role. This makes the important information available authentically and promptly and is quickly at hand.

Paper form

Currently, doctors' letters are usually sent in paper form. For this purpose, letterhead is used that contains the name and address of the clinic, the logo, the bank details and, in Germany, the institution code. Often there are further contact details for the respective hospital department, such as special consultations and those responsible. The design of the doctor's letters should be based on the regulations of DIN 5008 writing and design rules for text and information processing of the German Institute for Standardization or ONR 112203 Medical Informatics - Patient Letter and Doctor's Letter of the Austrian Standards International .

Short doctor's letters are usually written by hand on preprinted forms. However, it can also be a first draft of the later detailed report, which has not yet been read and, if necessary, corrected by all signatories .

The classic compilation of the patient file from contributions to the doctor's letter in paper form has several weaknesses:

• Risk of loss (especially of individual documents),
• high effort when several practitioners cooperate,
• poor findability of individual information with large amounts of data,
• no automated evaluation (e.g. comparison of findings, automatic output of vaccination reminders, etc.),
• Access to and changes to this information cannot be logged and cannot be assigned.
• insufficient quality of evidence and evidence for billing

Electronic doctor's letter

With the electronic version of the doctor’s letter, it is sent to the doctor who will carry out further treatment without paper. This requires communication between the practice software / doctor software and the hospital information system.

Electronic patient record

→ Main article : Electronic patient record

The electronic doctor's letter is part of the doctor's electronic patient file (EPR). It is crucial for medical care that all those involved in treatment are equally informed. So far, there have been delays or even incorrect treatment due to a lack of information. It is therefore important that in the future there is a file in which all the necessary data is compiled.

Individual electronic patient record

→ Main article : Electronic health record

So that health data are always available to the patient when they are needed, insured persons will in future have the option of keeping an "electronic patient file" - as a supplement to the medical documentation - as a separate set of information, printable in corresponding documents . This electronic patient record can contain doctor's letters, laboratory values, ultrasound or X-ray images.

Practical advantages

• The individual medical history is documented.
• All documents are there where they are needed.
• Time-consuming and costly double examinations (X-rays, etc.) are reduced.
• Together with the doctor, the insured parties decide which data will be saved in their patient files and who can see them.
• With the health card, insured persons can check what their patient files contain at any time.
• Your doctors can collaborate better across the board.

Standardization and standardization

On the basis of international standards of the ISO / HL7 accredited standards committees, a guideline for the implementation of an information technology support solution was issued for Germany, which describes the minimum requirements. In the meantime, a new version was published in 2015. The recommendations follow the reference information model (RIM) and the specifications of the so-called Clinical Document Architecture (CDA) for data exchange.

State of medical science

The standards of the ISO / HL7 committees describe the current state of the art, which is generally recognized. According to the German Social Code Book V §2 (Services) Clause 1 (generally recognized state of medical knowledge and medical progress), the indirect application of these standards in clinical practice is required. There is no further explicit recommendation or requirement in Germany.

Creation

While doctors' letters used to be dictated directly to a secretary or by dictation machine , these days they are created with speech recognition software or data from the hospital information system or the electronic patient file are used. The creation can also be done via text generators on the web. The preparation of the letters assumes that all findings from investigations that have been initiated are already available. In the case of tissue and microbiological examinations, this can sometimes take a longer period of time than hospital treatment takes today. Since every doctor's letter in the hospital is read and, if necessary, corrected by all signatories ( chief physician , responsible senior physician and supervising ward physician ) in the sense of a multiple eyes principle , there are often delays in the transmission of discharge reports. These are often only available in their final form to the doctor giving further treatment weeks after the completion of hospital treatment.

privacy

The German Medical Association and the National Association of Statutory Health Insurance Physicians have summarized and published the principles for maintaining medical confidentiality and data protection , including when sending medical letters , as well as the Federal Dental Association and the Federal Association of Statutory Health Insurance Dentists .

Legal Status

The patient is the owner of the personal information in the doctor's letter.

The obligation to compile the doctor's letter results, for example, from the Social Code Book V §73 sentence 1 number 3 in the wording: Documentation, in particular the compilation, evaluation and storage of the essential treatment data , findings and reports from outpatient and inpatient care .

Archiving

A copy of the doctor's letter remains as part of the patient file and must therefore be archived for 30 years after inpatient treatment in Germany and Austria. A retention period of ten years applies to the medical records of outpatients.

transmission

In Germany, data transfers to the doctor providing further treatment are based on Section 73 of the Book V of the Social Code . In Austria they are anchored in the state hospital laws of the nine federal states.

Delivery

Each patient can request that he be given a copy of the doctor's letter with attachments.

Reward

According to GOÄ no. 75 of the schedule of fees for doctors , the detailed written report of the illness and findings (including information on the anamnesis, the finding (s), the epicritical assessment and, if applicable, the therapy) is rewarded (€ 17.43 if the 2.3- multiple sentence). However, the notification of findings or the simple report of findings is covered by the fee for the underlying service.

Inquiries from statutory health insurance companies

For inquiries from statutory health insurances, forms according to EBM (numbers 01610 to 01623) of the uniform assessment standard are reimbursed - the corresponding EBM numbers must be noted on the form. Any further inquiries will be remunerated according to the GOÄ.

Inquiries from the MDK

The doctor does not receive any remuneration for simple information, certificates, etc. and there are no agreed forms for this. In the case of detailed reports, a form is agreed and the remuneration is made via EBM number 01621.

Inquiries from pension funds

The pension insurance funds pay for free reports and expert opinions according to the compensation guidelines of the German pension insurance. For a report on the application for participation benefits , for example, a flat rate of currently EUR 20.00 plus a flat-rate administration fee of EUR 7.20 to cover the writing fees, postage and the costs for attached photocopies is paid.

This practice is criticized by the German Medical Association as unlawful, because it is information that the pension insurance institution uses as evidence as part of its duty to clarify the facts . If the doctor is called in in this way as a witness or expert in administrative or court proceedings, he is analogous (see Section 21 Paragraph 3 Clause 4 SGB X) or directly in accordance with the Judicial Remuneration and Compensation Act (Appendix 2 to Section 10 Para . 1 JVEG ). For reports without an expert opinion, the doctor can demand an expense allowance of 21 euros (JVEG, Annex 2, number 200). The reimbursement of expenses takes place separately.

Inquiries from pension offices

The pension offices also remunerate reports in accordance with Appendix 2 to Section 10 (1) JVEG. The pension offices do not use a uniform Germany-wide template for submitting a report, but they are mostly designed in the same way in the federal states (e.g. Hesse).

Comprehensibility

In 2019, scientists from the Heinrich Heine University in Düsseldorf led by the linguist Sascha Bechmann, author of a book on medical communication , published the evaluation of a survey among 197 German family doctors as part of a research project. Almost 99 percent stated that they sometimes would not understand doctor's letters straight away, almost all (99 percent) stated that they had already received incorrect information in a doctor's letter - for example, discrepancies to the attached findings - and 88 percent were of the opinion that incomprehensible and incorrect information in doctor's letters can lead to treatment errors. According to the survey, general practitioners believed that the highest error rates were with discharge medication (76.6 percent), while 99 percent of respondents rated it as particularly important, followed by therapy recommendations (around 74 percent) and epicrisis . One problem would be the arbitrary use of abbreviations that can be ambiguous. 34 percent of the doctors surveyed complained about the frequent use of unknown abbreviations. Another point of criticism were cumbersome descriptions. As reasons for the deficiencies, Bechmann cites a lack of training in writing doctor's letters during studies and a chronic lack of time. According to Bechmann's study, a family doctor has to read an average of three to ten doctor's letters a day, which can take an hour, and clinicians need up to three hours a day to write the doctor's letters. The study also criticizes the use of ready-made text modules and different formats and recommends more structured and standardized doctor's letters.

literature

• Markus Unnewehr, Bernhard Schaaf, Hendrik Friederichs: Optimizing communication . In: Dtsch Arztebl Int . tape 110 , no. 37 , 2013, p. 1672-6 ( aerzteblatt.de ).
• Rolf Glazinski: Optimally designing doctor's letters, guidelines for creating medical reports in clinics and practices, study book on medical reporting . BoD, 2014, ISBN 978-3-7322-5596-2 .
• K.-W. Jauch: The doctor's letter. In: Jauch, Mutschler, Wichmann: Basic training in surgery. Springer, 2007, ISBN 978-3-540-34004-1 .
• Carsten Müller, Jörg Braun: Clinic guidelines for all wards. Basic guidelines for clinical traineeships & PJ . Elsevier, Urban & Fischer Verlag, 2008, ISBN 3-437-41562-X ( limited preview in Google book search).
• Karin Bock, Axel Valet, Kay Goerke, Joachim Steller, Karin Bock: Clinical Guide Gynecology, Obstetrics . Elsevier, Urban & Fischer Verlag, 2003, ISBN 3-437-22211-2 ( limited preview in Google book search).
• Norbert Schwenzer, Arzu Agildere, Thomas Becker: Tooth-mouth-jaw medicine. 1. General surgery . Georg Thieme Verlag, 2000, ISBN 3-13-593403-9 ( limited preview in the Google book search).
• Wolfgang Frank: Psychiatry . Elsevier, Urban & Fischer Verlag, 2007, ISBN 3-437-42601-X ( limited preview in Google book search).
• Reiner W. Heckl: The doctor's letter: A guide to clinical thinking. Thieme Verlag, 1990, ISBN 3-13-640002-X .
• W. Doeschel: Use of the doctor's letter for further treatment of the patient. Dissertation , Ludwig Maximilians University Munich , 1980.
• I. Judge: On the history of the doctor's letter . In: The German health system . tape 24 , no. 44 , October 1969, p. 2106-2109 , PMID 4916203 ( europepmc.org ).

Individual evidence

1. ↑ »The doctor's letter should be short and contain the essentials.« (PDF; 413 kB) MHH Info June / July 2006
2. ↑ Doctor's letter based on the HL7 Clinical Document Architecture Release 2 for the German healthcare system. (PDF) accessed on March 8, 2019.
3. ↑ Management paper "Electronic doctor's letter". .
4. ↑ Electronic doctor's letter: standards facilitate exchange .
5. ↑ Electronic patient record ( Memento of the original from June 25, 2009 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
6. ↑ ISO / HL7 21731: 2006, Health informatics, HL7 version 3, Reference information model, Release 1 .
7. ↑ Guide to the doctor's letter 2006 (PDF; 6 MB)
8. ↑ Guide to the doctor's letter 2014 (PDF; 19 MB)
9. ↑ HL7 Reference Information Model Version RIM_0204
10. ↑ ISO / HL7 27932: 2009, Health informatics, Data Exchange Standards, HL7 Clinical Document Architecture, Release 2, Media
11. ↑ Doctor's letter manager (web-based text generator for doctor's letters)
12. ↑ Jörg Burkowitz: Effectiveness of medical cooperation relationships - out of sight, out of mind ...? Empirical analysis based on patient data. ( Dissertation ), Humboldt University Berlin , 1999
13. ↑ Recommendations on medical confidentiality, data protection and data processing in the medical practice of the Federal Medical Association in Deutsches Ärzteblatt, vol. 105, issue 19 of May 9, 2008
14. ↑ Data protection and data security guidelines for the dental practice EDV KZBV, (as of September 2013)
15. ↑ Medical care .
16. ↑ Martin Dinges: Clinic Archive Recommendations: Assistance for the administration of files. Dtsch Arztebl 1996; 93 (43): A-2762 online
17. ↑ Legal basis of documentation. ( Memento of the original from October 25, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 86 kB) in Maria Strutzmann: Nursing process and nursing documentation in intensive care units. Klagenfurt, 2004. 
18. ↑ Doctors sink into the flood of inquiries from the Ärztezeitung on May 31, 2010
19. ↑ Markus Wenning: Remuneration for findings reports and expert opinions by pension insurance institutions and their working groups. online (PDF document, 62 kB)
20. ↑ Study on doctor's letters , University of Düsseldorf, April 17, 2019
21. ↑ Franziska Draeger: Sick Writing , Der Spiegel, No. 34, j17. August 2019, p. 101
22. ↑ Doctor's letters often incomprehensible , Ärzteblatt April 23, 2019