What a doctor in your patient’s file put

Each week, reply to Edwin de Vaal (46), a general practitioner in Nijmegen, a faq or a striking question from his practice. This week is: How does the general practitioner your patient?

The Pale: “In the Netherlands general practitioners of each patient’s medical record. In the past it was that paper done – the so-called ‘green card’ – today is all in the Electronic Patient Dossier (EPD). The doctor is the administrator of this, but you are as a patient owner. You have therefore the right to the file on request.”

“Every time you have contact with your gp, the nurse or the nurse, is there a report made in your dossier via the so-called SOUP-method. It doesn’t matter if it is a mail, phone call, visit or consultation.”

“At the S of ‘subjective’ is briefly written down with what story you to the doctor, what to ask the doctor you set and the expectations you did. For example, that you suffer from your ear and that you want that your ear is examined. Therefore, it is useful to have advance to think about what you ask for you doctor.”

“The O of ‘objective’ research is that the doctor does as a result of your story. Considering the above example is thus noted that the doctor in your ear looks and what exactly is seen. This has the advantage that it is not only now that is clear what is seen and measured during the research, but is also relevant for a next time.”

In short

  • As a patient, are you the owner of the medical record, but the doctor manages to
  • The doctor keeps in a structured way your information
  • As a patient you can ask to see the dossier or a targeted printout of this
  • A file goes with you if you like your doctor switch. This goes digital and is tightly secured

Also personal data are on file

“With the E of ‘evaluation’ is then the (provisional) diagnosis wrote: the doctor suspect an ear infection.”

“At the P of ‘plan’ is listed what will happen. The doctor suggests to wait and see, recommends a nasal spray to use, or refers you to a specialist. This plan is, where possible, in consultation with the patient, put together; you take your so along with the doctor to make a decision on the next steps.”

“Further, in the file, for example, results of the hospital and messages (letters) of specialists. In addition, your personal data also in and who else is on your address and at the practice are registered.”

As a patient, are you the owner of the file, you may on request inspect. ()

Gp, pharmacy and hospital keep separate records

“If I have a patient redirect to the ent doctor, then a referral letter with a summary of relevant information and usually also a specific question of me. Perhaps you have often suffer from your ear or you have tubes. That the purpose of the investigation or a treatment plan is very useful information for a specialist and so you don yourself not to remember.”

“You go to a (medical) specialist, has his own system for everything. This is not, therefore, automatically in the case of the general practitioner. If the specialist something important to say, usually if the treatment is completed, a summary message to the general practitioner sent via a secure e-mail.”

“If you go to another doctor moves, moves the file digital with you”
Edwin de Vaal, general practitioner

“Also, the pharmacist shall keep a file. This is what medications you now and in the past have used and if there are any allergies. The pharmacist checks the medications that I as a doctor recommend or ‘merge’ with any other drugs.”

“You move to an other doctor, than move the file digital with you. And after the death of a patient, a file is always fifteen years kept. Then it is destroyed, unless there is good reason to make it longer to keep it.”

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