Changes in medical records regulations. It is about EDs

The draft regulation aims to adapt medical records to situations involving the possibility of referring a non-emergency patient from a hospital emergency department (ED) to primary health care (PHC) sites without having to wait for an on-call ED physician.

Currently, medical dispensaries keep records in accordance with the Regulation of the Minister of Health of April 6, 2020 on types, scope and models of medical records and the manner of their processing (Journal of Laws of 2022, item 1304 and 1990, and of 2023, item 1486), which includes the medical rescue team departure order card. Due to the transition of medical dispensaries disposing of ground teams into the structures of provincial offices, which took place on January 1, 2022, the medical emergency team departure order card should not be subject to the regulations of the Medical Records Ordinance. On the other hand, the medical rescue team departure order card issued by a medical dispatch center located in the structures of a medical entity such as the Air Ambulance remains a medical record. In the case of refusal to admit a patient transported by a medical rescue team, including by an air ambulance team to a hospital, it is important to note this decision in the medical record, which is already the case, but is not explicitly included in the law.

In addition, the issue of keeping medical records by dispatchers of medical rescue teams, in the event of a system failure, as referred to in Article 24e (1) of the Act of September 8, 2006 on State Emergency Medical Services (Journal of Laws of 2023, item 1541 and 1560), requires regulation.

With regard to the issue related to the referral of patients from the ED to non-emergency health care delivery sites without waiting for an ED physician, the medical segregation card is given the status of an individual medical record both internally and externally. In a situation where a non-emergency patient is referred by a triage officer to ED treatment sites, the medical segregation card signed by the triage officer will be the document terminating the patient's stay in the unit and issued to the patient. On the other hand, in a situation in which a patient, after medical segregation, remains in the unit awaiting contact with an ED physician and further provision of health services in the unit, the medical segregation card will be an appendix to that patient's medical history.

At the same time, with regard to a patient who, as a result of medical segregation in the ED, was redirected by the triage officer to primary care delivery sites, the department's patient list will be limited in scope. Instead, it is necessary to note in it the information about the redirection and identify the referrer to primary care.

In addition, an annotation related to the refusal of admission of a patient transported by an emergency medical team to a hospital, along with the indication and signature of the person authorized by the medical entity to make such a decision, has been added to the medical emergency card and the air medical card of the emergency medical team - as individual patient documentation. Information in this regard will be recorded in the departure order sheet and the discharge order sheet of the emergency medical team.

Regulations relating to the emergency medical team departure order card were removed from the regulation, while the content of the emergency medical team departure order card was referred to the amended regulation.

The proposed regulation regulates the manner in which medical records are kept, exempting persons issuing a printout of medical records created in the system, referred to in Article 24e(2) of the Law on State Emergency Medical Services, to the patient or entities entitled to it from additional activities related to signing each of its pages due to prior authentication in the system of all data of the person entitled to it. In addition, the procedure in the situation of failure of the ICT system in which the dispatcher of medical rescue teams prepares medical records was regulated. In such a case, the documentation is prepared in paper form, and after the malfunction ceases, the documentation is immediately recreated in this system. Such a solution is necessary to implement due to the need to maintain the consistency of the data processed in the teleinformatics system referred to in Article 3 point 15 of the Law of September 8, 2006 on State Emergency Medical Services.

Source: RCL