PlusOnline deals with 8 questions about the medical file. Can you see it for yourself? And can you change something?
What’s in it?
All information that the doctor considers important: the symptoms you have reported, the diagnosis and any medications. Results of tests, such as blood pressure, are also included, as well as what the doctor tells you about it. In addition, the doctor can mention lifestyle, such as smoking and exercise. And he writes down psychological matters and records about your family.
Why does the doctor make such a comprehensive report?
Since 1995, doctors and dentists have been obliged to do so under the Medical Treatment Agreement Act (WGBO). Also nurses and paramedics such as
physiotherapists must keep a file. Pharmacists not (yet).
What are the advantages?
A written file enables better treatment. When another doctor or healthcare provider takes over the treatment, a good file becomes even more important. And if something goes wrong, the file is an important touchstone for the Medical Disciplinary Court.
And the cons?
The file costs the practitioner more time than before. For patients, there is a threat of invasion of their privacy. Due to their professional secrecy, doctors are not allowed to give information about you to third parties. However, a file with the GP can be viewed by the practice assistant. And that while two-thirds of the patients think that the assistant should not read details about the home situation without their permission.
Who can see it?
As a patient, you can view your own file or request a copy on request. You have to pay the copy costs yourself. A partner may only view a file with the patient’s consent. For children up to the age of 12, the parents or guardian may inspect the file, and for the incapacitated, their representative. After death, a doctor may only allow relatives access if he believes that the deceased had no objection to this. In addition to the practitioner, his/her observer has access to the file, just like fellow practitioners. In practice, however, it is not always clear who is regarded as a co-practitioner.
Can you change something yourself?
If you want to add or remove something from the file, you can submit a request to the doctor. This will usually be granted without hesitation. If a difficult relationship underlies such a request for change, the relationship between doctor and patient can be broken. The file is then sent to the new doctor.
Do all practitioners have access to the file?
New. Everything is stored in the computer – as an electronic file – but it is (still) technically difficult to link all information together. In addition, unauthorized persons must be prevented from looking into files. It is also desirable that co-practitioners only have access to the relevant part of the file. The municipality of Nieuwegein had the scoop in 2005: GPs, specialists and pharmacists have since been able to view summaries of each other’s files. In 2007, Rotterdam and Amsterdam, among others, started the electronic exchange of the medication use of patients between general practitioners, pharmacists and hospitals.
Can you keep a medical file yourself?
Yes. This can be done, for example, on the internet via Medlook, for €12 per year. A small number of pharmacies in our country offer this option for free and put your medicines in the internet file. Look at the site www.medlook.nl For more information. There has also been a so-called SOS chain for a long time, containing, for example, a warning for a penicillin allergy or diabetes. And of course you can always put a list in your diary, for example, with all the medicines you use.
Sources):
- Plus Magazine
