Medical records are of vital importance. They help healthcare professionals keep track of your health and make decisions about the care you need.
Medical records help with follow-up and communication
Every healthcare facility or private clinic you visit keeps a medical record in your name. In the past, these records were on paper. Today, paper records are gradually being replaced by digital ones.
This medical record contains your personal information and a history of all the healthcare and health services you’ve received.
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Important Your medical record may have been deleted if it was inactive for more than 10 years. |
Personal information and contact details
Your medical record must include information that identifies you and information that allows the healthcare facility or clinic to contact you.
The law doesn’t specify what details doctors must record, but usually your medical record will have your name, date of birth, address and health insurance card number, if you have one.
Health condition and treatments
Doctors also record information about your health and treatments in your medical record. For example:
- a summary of your overall health, if your doctor sees you regularly,
- known allergies or intolerances,
- test results and diagnoses,
- treatment plans and medications prescribed to you,
- any emergency, or situations that could become emergencies,
- any accident or incident that occurred during treatment and that might affect your physical or mental health, along with steps taken to reduce harm or prevent it from happening.
Consents given
Your medical record also includes any consents you gave, or any consents a representative of yours has given on your behalf. For example:
- your consent to medical care,
- your consent to being photographed or recorded,
- your consent for the clinic to contact you by a technological means, like email or phone,
- your instructions in case of resuscitation, if need be.
Communications and invoices
Your medical record also contains a summary of all communications the healthcare facility or clinic has with you, or with another person like a family member or a healthcare professional.
For remote consultations, your doctor also records where you are and who else is present during the call.
Invoices and receipts are also added to your record.