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Draft amending the Regulation of the Minister of Health of medical records

🟠 Draft amending the Regulation of the Minister of Health on types, scope and models of medical records and the manner of their processing

The planned changes will allow:

🔸 relieve the burden on ED wards by referring a patient not requiring immediate diagnosis and treatment to the PCP, including night and holiday care (NON-HIV) directly after segregation in the ED (triage), i.e. by a person authorised to perform triage without the participation of a doctor . It is planned to have an NICU at each ED by 31 December 2023.

🔸 Protection of emergency and air ambulance teams against patient claims in the event that the patient or the patient's legal representative opts out of transporting the patient to hospital.

🔸 protection of emergency medical teams and air ambulance teams against claims by the patient in the event of refusal of hospital admission.

🔸 Maintenance of medical records by the dispatcher of medical rescue teams in paper form in the event of failure of the SWD PRM system.

The amendment of the regulation includes:

📌 introduction of a medical segregation card, replacing the information card for hospital treatment, when performing medical segregation is the last stage of the patient's stay in the ED.

📌 amending the ward's list of patients by introducing an annotation of the patient's referral to the primary care setting by the person carrying out medical segregation in the hospital emergency department and marking the person carrying out the triage. In the case of a patient referred to a PCP or NICU after triage, information regarding the attending physician, discharging physician, diagnosis, discharge or death of the patient will not be completed in the patient list.

📌 Entry of a medical declaration by the patient or his/her legal representative to refuse transport to hospital with the date and the hour, minute and second of the refusal in the 24-hour system.

📌 introduction of an entitlement for the dispatcher of the emergency medical team to maintain paper medical records in the event of a failure of the SWD PRM system, with the obligation to immediately restore them in the system once the failure has ceased, and an obligation to digitise the records produced on paper.

🔸 The deadline for comments is 20 October 2023, Friday

‼️If you want us to comment on your behalf: send information with your comments to by 17 October 2023.

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