The French Decree of 4 January 2006 stipulates that “the medical file must be stored for a period of 20 years from the date of the last stay by its holder in the institution or of the last outpatient consultation at the institution”, which, in addition to France’s Kouchner Law of March 2002 which allows patients access to their files, obliges professionals to put in place effective document management solutions.
For example, one of our clients in Lyon has seen his requests for records consultation increase fourfold since 2005, which today represents an average of almost two search requests per day.
Patients can access their records
- Directly or through a doctor whom they have nominated for this purpose :
at the earliest after a 48-hour waiting period, and at the latest within 8 days of their request (or 2 months if the information goes back more than 5 years).
- Information can be provided in situ or send in paper copy or electronic form.
- Copying and postal costs are payable by the applicant.
« The patient record is an information-sharing tool, and is a vital element in the quality of care, allowing continuity of care within the framework of multi-professional, multi-disciplinary treatment ».
It must provide traceability of all actions carried out.
To be an effective tool, it must be :
- Structured, useable and legible,
- Comprehensive and organised,
- Secure and easily accessible by authorised staff,
- Computerised to guarantee total traceability of contents (Who is adding, who is enriching, who is consulting ?)
Who do these obligations concern :
According to the French Order of 5 March 2004, they concern all medical and paramedical professions.