Medical history

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This article or paragraph presents the situation in Germany . Help us to describe the situation in other countries.

In everyday life, medical history is a synonym for documentation of previously closed cases . This forms the basis of the anamnesis for a new case ( case ) of the same patient , i.e. In other words, it supplements the information about the patient's state of health that the doctor collected during the conversation at the beginning of the treatment.

A complete medical history consists of a history (anamnesis), findings ( status praesens ), supplements (further examinations and the most important entries about the course of the disease with information about the type and success of the treatment ) and a summarizing final analysis ( epicrisis ).

According to common professional language in a health care facility, the patient record is the entirety of all documented information about the currently treated case of a patient . This documentation about the current case must be represented by the treating institution of the health care system.

The creators of the original documents are responsible for the documentation of previous cases that the patient may bring with him as a medical history. However, the patient himself must represent the completeness of the medical history. These original documents remain in the treating facility. The patient has the right to request a copy . The patient must bear the costs of production.

Usually, documents on the medical history of one or more previous cases of a patient, i.e. the currently valid medical record or patient record in paper form and with individual images or data carriers - at best combined as an electronic case file (EFA) - are individually sent to the requesting institution by each of the health care institutions concerned and usually made available on loan.

Central archiving of the medical history is neither regulated by law nor generally available in Germany. In countries with a public health system, such as the United Kingdom, or in countries with a fully networked health system, such as Sweden, approaches are being pursued which should contribute to better information availability. An international standard has not emerged from any of these approaches. Private-sector approaches to documenting medical history are not widely used and appear to be less successful.

For health insurance , the question of previous illnesses to be clarified as part of the health check, i.e. illnesses that existed before entering into the insurance, is important.

Contents of the patient record

The work of doctors and nurses in the hospital is largely based on a division of labor . Therefore, everyone involved is forced to not only communicate verbally with one another: the patient file is a means of communication for the teams involved. The patient file first serves as a self-control for the senior physician and then as a means of communication with other treating colleagues and the nursing staff involved.

The attending physician is responsible for the completeness of the medical history. There are guidelines in Germany regarding the form, archiving and handling of patient history data. In terms of content, the patient record includes the complete course of a patient's case. In this way, a patient file with a few tens of sheets is usually created in paper form. The patient record includes, for example

  • Identification documents, such as the patient data sheet ,
  • Documents for admission:
    • the induction report
    • a detailed anamnesis ,
    • the admission findings
    • the documentation of the examinations carried out
  • of documents on invasive measures:
    • a preliminary and a final OP report
    • the anesthesia protocol,
    • the documentation of the blood products received,
  • on documents for commissioning other departments:
  • of continuously updated documents
    • the medical record and
    • the care sheets ,
    • the curve,
    • the sheets on which complications are documented as well
  • on documents without a special form
    • Notes on special incidents
  • of documents for further progress:
    • the pharmacological prescriptions
    • the medical and nursing report from the intensive care unit ,
    • warnings given to the patient,
  • the documentation of the therapeutic measures carried out
  • on documents for discharge:
    • the discharge letter,
    • the preliminary doctor's letter
      • the physical status and
    • the final doctor's letter,

The findings and doctor's letters mainly contain narrative medical information. The compilations for the time between admission and discharge are specific for each case and different for the respective specialist clinic.

Electronic registration

In the meantime, electronic patient files (computer-aided systems) are used almost exclusively for the organization of patient files in practices and hospitals . Completely paperless electronic documentation can be approved as "digital evidence" in civil proceedings if the documentation is protected against subsequent changes and / or the plausibility of the documentation and its subsequent immutability can be demonstrated to the court. If the electronic documentation is also provided with a qualified electronic signature in accordance with the Signature Act , the evidential value of the documentation is further increased.

Contract document

In addition to its central function for medical communication, the patient file fulfills the meaning of a legal document . The entries can be used as evidence in court. This is relevant, for example, in proceedings that involve the proof of a medical malpractice or billing fraud. For health insurers, the medical history is important as a basis for billing.

Further content on the medical history

If available, the medical history summarizes the contents of successively created patient files. It thus proves the measures taken during an illness in the respective institutions involved to monitor the progress. It gives the health staff an overview of the diagnoses and therapies and also includes the observations made by the nursing staff.

Information rights

Patients have the right to view their medical records and have copies made. Patients with statutory health insurance in Germany also have the right to have a patient receipt (cost information) for the billed services issued free of charge by the contracted doctor or psychotherapist ( Section 305 SGB ​​V ). There is also the option of requesting data from the responsible Association of Statutory Health Insurance Physicians (KV): At the request of an insured person, the KV must release all available social data, according to the Federal Social Court. Decisive is § 83 SGB X . The information is to be given free of charge.

Legal basis

With the patient rights law , the doctor or dentist was obliged by § 630f BGB - as previously regulated in the professional regulations and in the federal shell contracts - to keep a patient file and to document all relevant facts, including the findings, in detail. Subsequent changes in both the paper and the electronic patient file must show the specific content and the exact time of the change.

The sample professional regulations of the German medical profession (basis of the generally identical, binding state professional regulations of the state medical associations) lays down in § 10 the scope of the documentation obligation, the retention period and the obligation to allow the patient to inspect. It is still being adapted in accordance with the new provisions of the Patient Rights Act.

Right to inspect patient files

§ 630g BGB grants the patient the right to inspect his patient file and, if necessary, to receive copies of the briefcase in paper form or duplicates of the electronic documentation and images for reimbursement of expenses. The right of inspection and duplication also applies to his heirs and next of kin in accordance with Section 630g (3) BGB. As a rule, this will be done in the practice or clinic, but this can also be agreed otherwise. Inspection may only be refused "if there are significant therapeutic reasons" or "other significant rights of third parties" opposing it.

The right of inspection now also results from the right to information under data protection law in accordance with Art. 15 GDPR. The right to information in accordance with the General Data Protection Regulation is free of charge for the patient, so that, due to the priority of application of Union law , the patient may not be charged any costs for inspection on the basis of the treatment contract - even contrary to the wording of Section 630g (2) BGB.

Burden of proof in case of violation of the documentation obligation

If the treating person has not recorded a medically required essential measure and its result in the patient file contrary to Section 630f or if he has not kept the patient file contrary to Section 630f (violation of the documentation obligation ), it is assumed that he did not take this measure, which means that in the legal dispute this can result in a reversal of the burden of proof to the detriment of the doctor ( Section 630h (3) BGB)

Anonymized evaluation

In epidemiology archived patient records serve as an important source of information. Medical histories of individual patients also serve as illustrative material in the context of medical studies and advanced medical training. Under the catchphrase “problem-oriented learning”, such practice-oriented teaching components are increasingly being integrated into the curriculum at medical faculties.

history

In the Edwin Smith Papyrus , a copy of a text from the 16th century BC. 48 surgical cases have been described; with description of the symptoms, diagnoses and prognoses according to the pattern “one can cure”, “one can perhaps cure”, “one cannot cure”. The Ebers Papyrus contained descriptions of symptoms and their diagnoses, instructions for treatments and recipes for remedies, for example for injuries, illnesses, parasites and dental problems, but also for contraception. Around 400 BC Hippocrates used Patient related medical histories.

In modern times, this form of medical documentation was rediscovered in the 16th century AD, for example St. Bartholomew's Hospital in London set up a Medical Record Department on the instructions of Henry VIII . In 1526, the Nuremberg city doctor Johann Magenbuch kept a chronological diary with the names of the patients, information about their illnesses, medication prescriptions and the course of the illness. In contrast to the current form of patient-oriented medical history, such medical diaries had a private character; as journals, they primarily served to expand the knowledge of the individual doctor and represented his or her personal wealth of experience. American hospitals were still using such (ward-related) case books in the 19th century.

In Germany, the transition to patient-centered, standardized medical records took place earlier; For example, patient files from the 1850s can be found in the Charité archive .

See also

Web links

Wiktionary: Medical history  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ↑ Hans von Kress (ed.): Müller - Seifert . Pocket book of medical-clinical diagnostics. 69th edition. Verlag by JF Bergmann, Munich 1966, pp. 1-4 ( medical history ).
  2. ^ Google Health will be discontinued as a service.
  3. ↑ Evelyn Weis: The medical documentation - analog or digital? Ass. Iur. In: Anästh Intensivmed. 2013, 54, pp. 319-322.
  4. ↑ Federal Social Court, Az. B 1 KR 12/10 R
  5. ↑ (Model) professional code for doctors working in Germany. Frankfurt am Main 2015 (PDF; 1.2 MB).
  6. ↑ Thomas Bayer: Medical documentation obligation and right to inspect patient files. An investigation into §§ 630f and 630g BGB with references to national and European data protection law . Springer, Berlin 2018, ISBN 978-3-662-57488-1 , pp. 221 ff .
  7. ↑ Thomas Bayer: Medical documentation obligation and right to inspect patient files. An investigation into §§ 630f and 630g BGB with references to national and European data protection law . Springer, Berlin 2018, ISBN 978-3-662-57488-1 , pp. 224 .
  8. ↑ Cf. for example Georg Sticker : Hippokrates: Der Volkskrankheiten first and third book (around the year 434-430 BC). Translated, introduced and explained from the Greek. Johann Ambrosius Barth, Leipzig 1923 (= Classics of Medicine. Volume 29); Unchanged reprint: Central antiquariat of the German Democratic Republic, Leipzig 1968, pp. 60–85 (42 medical histories from the epidemics ).
  9. ↑ Archived copy ( memento of the original from March 3, 2011 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. @1@ 2Template: Webachiv / IABot / www.bvmi.de

literature

  • Thomas Bayer: Medical documentation obligation and right to inspect patient files. An investigation into §§ 630f and 630g BGB with references to national and European data protection law. Springer, Berlin 2018, ISBN 978-3-662-57488-1 (also dissertation, Munich 2018).
  • K. Böhm, CO Köhler, R. Thome: History of the medical history. Schattauer, Stuttgart 1978, ISBN 3-7945-0606-5 .
  • Robert Jütte : From the medical case to the medical history. In: Reports on the History of Science 15, 1992, pp. 50–52.
  • C. Lichtenthaeler: History of Medicine. German Doctors-Verlag, Cologne, ISBN 3-7691-0036-0 .
  • S. Timmermans, M. Berg: The Gold Standard . Temple University Press, Philadelphia (USA) 2003, ISBN 1-59213-188-3 .
  • Werner Vogd: Medical decision-making processes in the hospital in the field of tension between system and purpose rationality. VWF, Berlin 2004, ISBN 3-89700-404-6 (plus habilitation thesis, Berlin 2004).