Medical Documentation

Original Language Title: o zdravotnické dokumentaci

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Read the untranslated law here: https://portal.gov.cz/app/zakony/download?idBiblio=77217&nr=98~2F2012~20Sb.&ft=txt

98/2012 Sb.



DECREE



of 22 March. March 2012



medical documentation



236/2013: Sb.



The Ministry of health shall, pursuant to section 120 of the Act No. 372/2011 Coll.

on health services and conditions of their provision (law on

health services), to implement section 69 (a). a) to (d)) of the

health services:



§ 1



(1) medical records, with regard to the scope of

health services, contains information about the patient's health and

the facts related to the provision of health services

the patient,



and) the identification of the provider, which are



1. the name or names, the family name of the provider,



2. the address of the place of delivery of health services in the case of a natural person,



3. the trade name or the provider name, address of the registered office or the address

the place of business in the case of a legal person,



4. the identification number of the person, if any,



5. the name of the Department or similar parts, if the health care facility

provider of structured as follows (hereinafter "Medical Department

device "),



(b) the patient's identification data), which are



1. the name or names, the surname of the patient,



2. date of birth, social security number, when allocated, the number of the insured person

public health insurance, if this number is not your social security number

the patient's health insurance company code,



3. the address of the place of residence in the territory of the Czech Republic, in the case of

foreigners, instead of reporting the stay on the territory of the Czech Republic, and in the case of

persons without permanent residence in the territory of the United States permanent address outside the

the territory of the Czech Republic,



(c) the sex of the patient)



(d) the name or names), surname and signature of the healthcare professional

or other professional worker who has made an entry into the medical

documentation; This does not apply in the case of a provider that provides

health services in its own name,



(e) the date of the writing to) the medical records, the date and time

the provision of emergency care or services for visiting execution

the patient,



f) stamp of the provider, if it is a part of the medical records,

which is passed on to the patient or under other legislation other

natural or legal person who is entitled to health

documentation,



(g) in the case of the provision of a one-day) or inpatient care date and time



1. the admission of the patient to the day or inpatient care,



2. termination of patient care,



3. transfer to another provider, or its transfer

the other Department of medical equipment,



4. the death of a patient,



h) information on the State of health of the patient, on the course and outcome of the

provided by the health services and other relevant circumstances

related to the medical condition of the patient and with the procedure when

provision of health services, including the anamnestic data needed

for the provision of health services,



I) for information about whether the patient is free of legal

a patient with limited capacity or competence to perform legal acts so that the

is not capable of assessing the provision of health services, where appropriate,

the consequences of their provision (hereinafter ' the patient free of

legal capacity),



j) for persons pursuing activities of epidemiologically significant ^ 1) record

the type of activity carried out.



(2) the medical records in connection with the identified information about

patient's health also contains



and the conclusions and final) the working diagnosis,



(b)) further treatment and information about the course of treatment,

If the medical condition of the patient requires,



(c) to the extent provided by the record) or on-demand health services,



d) record about current developments of health condition by rating

communicated to the patient and the targeted objective findings



(e)) record



1. the prescription of medicinal products, foods for special medical purposes,

including dosage and number of prescribed packing, or medical

resources,



2. Administration of medicines or foods for special medical purposes,

including urine; in the case of a blood product administration

a unique registration number of a blood product, including code

blood transfusion services, device that identifies the date and time and signature

the medical worker who handed, transfusion medicine



3. equipment the patient's medicines, foods for special

medical purposes, including quantity, or medical devices;



f) record the order to medical transport, including the type of

means of transport,



g) records of the nursing care that you made, including records of granted

nutritional care and hospital rehabilitation care,



h) record the implementation of vaccination, including the name of the vaccine and

batch number,



I) written consent of the patient or his legal representative, providing

health services, where the obligation of written form provides consent

another law ^ 2) or if, given the nature of the health

the performance was a consent in writing by the provider requested,



j) a record of the refusal to provide health services,



to use the record) restraints ^ 3) to the patient

contains



1. a record of the indication of restrictions including the specification of the kind, reason and purpose

limits and determination checks and their scale intervals,



2. start and end time use resource throttling



3. records of the duration of the interim evaluation of the reasons to use the throttling

resource,



4. the record of the interim evaluation of the health status of the patient during

restrictions,



5. in the event of the occurrence of complications in their description,



6. the name or names, and surname of the medical worker who

use resource throttling indicate; in the case that the use of

resource throttling neindikoval doctor, also the name, or names,

and the surname of the doctor, who was on the use of additional resource throttling

informed,



7. in the event that the use of neindikoval doctor, resource throttling

the record of a doctor to evaluate the merits of the restrictions, including the time when it

confirmed



8. information about the fact that he was the legal guardian of the patient is free of

the eligibility of legal capacity or of a minor patient shall be informed of

the use of restraints,



l) copies of medical assessments,



m) in the case of the provision of health care services also requested by requisition

exposed to another provider,



n) a record of the inspection of the medical records of a patient-led

with an indication of where, by whom, and to what extent the inspection took place, including the

make a copy or record of the statement from the medical records, if

were taken,



about) record the recognition or their temporary incapacity,

assessment of health status at the time of its duration, the data on the specified

mode temporarily work insured and its amendments, a record of the

start the necessary treatment and its length; a record of their temporary

incapacity to carry out the provider that the patient has led in

the registration of citizens temporarily incapable of work prior to its termination;

If the patient during temporary incapacity to work passed into the

registration of another provider or taken from another provider, it is

part of the medical records whether or not a record of the date of its transmission or

receipt,



p) sickness insurance institution records relating to the control

assessment of the health status, temporary incapacity and the need for

care,



q) records of other significant circumstances related with

the patient's status, which have been identified in connection with the provision

health services,



r) record of suspect doctor of the tortured, abused and syndrome

the neglected child, of the measures taken and of compliance with the notification

obligations in accordance with relevant legislation ^ 4).



(3) Medical documentation also includes records, components and other

the facts set out in law on health services and conditions

their provision, the Act on specific medical services or

other legislation ^ 5).



§ 2



Part of the medical records of the patient are kept by the



and the results of the examination in the form of) the written descriptions, graphics,

audiovisual, digital or other similar records these

examination, the operating Protocol, anaesthesia record



b) written information about discovered facts about the health

the patient, the course and termination of the treatment or advice and suggestions on

the provision of other health services that transmit to providers

in order to ensure continuity of health services about a patient,



(c)) in the case of inpatient care summary (epikríza) on the course

examination and treatment and plan further therapeutic approach, if inpatient care

lasts longer than 7 days,



d) in the case of occupational health services information about the contents and the conditions of

the work, which is a medical condition of the employee being monitored, including

information on the classification of the individual factors of the working environment to the appropriate

category ^ 6), the results of biological exposure tests, benefits

ionizing radiation and other data essential for assessing the impact of


working conditions for the health of the worker and the further written information on the

the current state of health, or its development passed authorising

provider in the field of general practical medicine,



e) records of the investigation, medical or administrative procedures

carried out pursuant to other legislation ^ 7), including records of

State of health of the patient, and copies of messages, information and data transmitted by the

under these regulations,



f) records of the occurrence of serious or unexpected adverse events in

connection with the provision of health services, with the administration of the medicinal

the product, with the use of a medical device, on the administration of

of the product in the clinical trial or the use of the medical

resource in the context of the clinical examination,



g) records of the implementation of the new procedures for authentication by using a method that

have not been in clinical practice on a live person introduced ^ 8),



h) record the reporting of suspected infectious diseases infectious disease, death

infectious or elimination of pathogens of infectious diseases locally

the competent authority to protect public health.



§ 3



(1) on each sheet of the medical records, the name, if applicable

name, last name and social security number, date of birth, the patient is not a native

the number allocated, the identification data of the provider, where appropriate,

the name of the Department of medical equipment.



(2) the components of the medical records referred to in Appendix 1 to this

the Decree, which are its separate parts, containing the information

laid down in this annex and further data and information according to § 1 (1). 1

(a). a), b), (d)) to (f)), if it is not in annex 1 to this notice

unless otherwise provided for.



(3) the implementation of writing to the medical records is the responsibility of

a medical worker or other specialist that the patient

provided by the health service.



§ 4



Part of the medical documentation of the emergency medical services are



and the audio recording of income) calls to national emergency number 155

and challenges of the different basic operating Centre passed folder

the integrated rescue system (hereinafter referred to as "emergency call"),



(b)) record carrier in digital form,



(c) a copy of the record of exit),



(d) the identification and sorting tab),



(e) the record of the mass expulsion) of patients.



§ 5



(1) the provider of leads and maintains medical documentation in accordance with the

the principles set out in annex 2 to this Decree; ensures

the assessment of the need for more provision of medical records

health services (hereinafter referred to as "the assessment of the need for") for the purpose of its

the decommissioning and destruction of or further retention. This applies to

the competent administrative authority, which under the law on health services

He took over the medical documentation.



(2) medical record shall be kept for 5 years and is referred to

a single-elimination with the "S", if there is no other legislation or in the

Annex No. 3 to this Decree provides otherwise. In the case of acquisition of

medical documentation of the relevant administrative authority, the time limit for

the retention period referred to in annex 3 to this Decree does not cut.



(3) the retention period for the medical records of a patient-led one

the provider shall begin on 1 January 2000. January of the following calendar

year after the date on which the last entry was made in the medical

documentation of the patient, if not in annex No. 3 to this notice

unless otherwise provided for.



(4) if the medical record or part of a patient-led

their assignment or material content are subject to several deadlines for its

the retention referred to in annex 3 to this Ordinance, the period of retention and

the knockout character shall be determined in accordance with the longest retention period.



§ 6



(1) in the case of the medical records kept in electronic form is

each record in the medical documentation provided with electronic

signature ^ 9).



(2) the technical means for keeping medical records in the

the electronic form will guarantee



and the security of computing) software and hardware

resources from access by unauthorized persons to medical

the documentation and



(b) records of all) keeping the approaches to medical documentation, including

their corrections, changes and lubrication.



§ 7



(1) on the medical documentation that began to be carried out before 1 July 2004.

April 2012, annexes 2 and 3 to this notice. If this

medical records expired retention period specified under paragraph 5, before the

the effective date of this Ordinance and shredding management was not implemented

or initiated under Decree No. 385/2006 Coll. on health

documentation, in the version in force until 31 December 2006. March 2012, the need for

assess from 1 January 2003. July 2013.



(2) if the medical records held before 1 May 2004. April 2012

started discarding procedure, according to the Decree completes the No 385/2006

Coll. on the medical documentation, in the version in force until 31 December 2006. March 2012.



§ 8



This Decree shall enter into force on 1 January 2000. April 2012, except

the provisions of § 1 (1). 1 (b). k), which shall enter into force on 1 January 2000. April

2013.



Minister:



doc. MUDr. Heger, CSc., r.



Annex 1



THE MINIMUM CONTENT OF THE SEPARATE PARTS OF THE MEDICAL RECORDS



1. LISTING of the MEDICAL RECORDS



Listing of medical documentation includes:



and) basic data from the patient's history, plus the information necessary for the purpose for

that listing is issued,



(b) the last detected) information for the patient's health and the breakdown

It used medicinal products, foods for special medical purposes

and use of medical devices,



(c)), the diagnostic summary



(d) a brief assessment of the development) of the health status of the patient,

including the response to previous treatment and the dynamics of development results

laboratory and other auxiliary examination,



e) other relevant information, including information from medical care.



2. request of OTHER HEALTH SERVICES (REQUISITION)



Request additional health care services includes:



and health service) required and the reasons for them, including the urgency of

the person providing,



(b) the last detected) information about health status, including the results of

laboratory and other auxiliary examination,



(c) details of the treatment so far) and the patient's response to it,



(d)) the working diagnosis,



(e) a brief evaluation of the data from the) history, if they have a link with the

the required medical services.



In the case of a request of the professional examination consisting of laboratory

examination, or in the use of instrumentation, in particular, ECG,

Ultrasound, x-ray, requisition has the information under (a)), and (e)).



Occupational health service provider shall indicate in the application of professional

examination in addition to the information about detected health status always data

the occurrence of risk factors and health performance of the work and the conditions

under which the assessed activities carried out.



3. the report PROVIDED by the HEALTH SERVICES



Provided by the health services report contains:



and information about detected) of health, including the results of laboratory and

other examinations,



(b) details of the treatment so far) and the patient's response to it,



(c) recommendations to the next) the provision of health services, including

the recommendations in the medical care.



In the case of a one-time provision of health services report contains

information about detected health status, including the results of laboratory and

other examinations and recommendations to further the provision of health

services.



In the case of on-demand expert examination consisting of laboratory

examination or in the use of instrumentation, in particular, ECG,

Ultrasound, x-rays, provided by the health services report contains

information referred to in subparagraph (a)).



4. Information about THEIR DAY or INPATIENT CARE (LAYOFF

Report)



A. Layoff report contains:



1. a brief statement of the history of and current diseases,



2. time and the course of a day or inpatient care that articulates why

the patient is hospitalized and what was the outcome of the diagnostic efforts

care and treatment,



3. the principal diagnosis, secondary diagnosis,



4. the record of previous treatment and the results of the examination, which

are essential for the provision of other health services,



5. Overview of the performed medical procedures, including their results and

possible complications,



6. recommendations to provide needed health care services, including

hospital rehabilitation and nursing care and diet recommendations

mode, medicinal products, foods for special medical purposes and

their dosage and recommendations of medical devices intended

providers that will provide more health care services, and

recommendations for health care assessments.



B. Preliminary layoff report contains:



1. General information about the course of hospitalization,



2. the principal diagnosis, secondary diagnosis,



3. a brief record of the previous treatment, rehabilitation and

nursing care, diet, including the placing of medicinal products,

foods for special medical purposes and medical devices, which

the patient is equipped




4. recommendations for further progress in the provision of health services.



5. The WRITTEN CONSENT to the provision of HEALTH SERVICES (HEALTH

PERFORMANCES)



A. written consent provides:



1. the information about the purpose, the nature, expected benefits, consequences and

the potential risks of health services,



2. guidance on whether proposed health services have a

an alternative, and the patient has the opportunity to choose from several alternatives,



3. the data on the possible restrictions in the normal way of life and in the work

After the granting of the relevant capabilities of health services, where such

restrictions to assume, and where changes in health status information about

changes in health,



4. data on treatment and preventive measures are

appropriate, and the provision of other health services,



5. refer to the right of the patient to decide freely about how to

provision of health services, if other legislation this right

do not exclude



6. a record of the patient, which has been implanted medical

resource, in the form of detailed information about implant

medical device under special legislation,



7. date and signature of the patient and the healthcare professional that

the patient information and instructions provided.



B. in the case of a minor patient or the patient's eligibility for free

legal capacity of the written consent shall imply that the relevant data

According to part and given the patient's legal representative, and also

the patient; If the patient were not provided such information, the

the reason for their failure to provide ^ 10).



6. A record of the REFUSAL to PROVIDE HEALTH CARE SERVICES (REVERSE)



A. record of the refusal to provide health services to a patient includes:



1. an indication of the health of the patient and the necessary health services,



2. an indication of the possible consequences of the denial of necessary health services

for the health of the patient,



3. record the observations of the patient, the information referred to in points 1 and 2 have been

medical professional and explained that they understood and that

He had the opportunity to ask supplementary questions, which have been a medical

worker answered,



4. the written declaration of the patient, or a record of this statement, that

Despite the explanation provided needed health services,



5. place, date, hour, and the signature of the patient,



6. the signature of the healthcare professional that patient information

provided,



7. If the patient with regard to their health status, sign or

refuses to sign the Declaration, the record for the record on behalf of,

where appropriate, the name, surname and signature of the witness, who was a speech

rejection of the present, and the reasons for which the patient has not signed,

and shall specify the manner in which he showed his will.



B. in the case of a minor patient or the patient's eligibility for free

legal capacity, the statement of denial of health services

to imply that the relevant information had been provided under this section and

the patient's legal representative, and whether or not the patient; If the patient has not been

such information is provided, the reason for their failure to provide ^ 10).



C. a record of the refusal to provide health services provider, or

medical professional or failing to care includes:



1. reason for refusal to provide health services, including a description of

health service rejected or not taking into care,



2. the date and time the refusal or failure to take care of.



D. written consent for the appeal is part of the A and B shall apply mutatis mutandis.



7. A record of the PREVIOUSLY STATED WISH



For a record of previously stated wish made when you receive care

provider, or at any time during the hospitalization shall apply mutatis mutandis

uses:



and part 5, and part). of this annex, if the subject previously express wish

consent to the provision of health services,



(b) part and part 6). of this annex, if the subject previously express wish

opposition to the provision of health services.



8. A record of the CONSENT to the provision of INFORMATION



A record of the consent of the patient or legal guardian with the provision

information about the State of health of a patient, includes:



and the) determination of the people to whom you can communicate the information, where appropriate, the determination of the people,

which communicate the information cannot be,



(b)) the range of information that can be used to communicate



(c)) the communication whether the designated person or persons the right to inspect

the medical records held on the patient and the right on the acquisition of its

a copy or extract,



(d)) the communication whether the designated person or persons the right to agree or

opposition to the provision of health services to a patient, if not

make the patient himself,



(e)) the communication of the manner in which the information can be provided (for example,

in writing, orally, by telephone, fax, email, SMS), including

the appropriate contact link,



(f)) the place, date and signature of the patient or of the legal representative and the signature of the

the medical worker who handled the record.



9. The MEDICAL REPORT



The medical report always includes:



and) identification



1. relationships in the range name or names, surname, date of

of birth, address of the place of residence of the person under consideration, or

place of residence in the territory of the Czech Republic, in the case of foreigners,



2. provider, on whose behalf the examining physician medical certificate issued,

and the identification number of the person, if any, address of the seat or

the place of business, the stamp of the provider,



3. the doctor who issued the opinion on behalf of the provider, and the name of the

where appropriate, the name, surname and signature of the physician,



4. serial number or other markings, registration



(b) the purpose of the Advisory opinion,)



(c) the medical conclusion)



d) instruction on the possibility of submitting a proposal for the review,



e) release date,



f) expiration date, if it is to be based on

the observed health status or medical fitness to limit its

force, or, if so provided by other legislation.



10. DOCUMENTATION PROVIDER of EMERGENCY MEDICAL SERVICES



Emergency medical services provider documentation is

the documents and records relating to a particular patient or

specific events, including audio recordings (records)

medical operations centre with the times.



A. the record carrier contains:



and) date, time and sequence number of emergency calls,



(b)) the personal data of the patient, and to the extent the name or names,

last name and birth date, if you can find out this information and data

needed to determine the place of intervention,



(c)), telephone number or other information about the possibility of connection to the caller,

If you can find out this information,



(d)) the personal data operator, which took the emergency call,



(e) the transmission of the emergency calls) time to exit the emergency medical group

emergency services,



f) indication of the trip.



Record operator is kept in electronic format, and archived on the media

with a longer lifespan of 5 years.



(B). A record of the trip includes:



In addition to the requirements listed in part also



and, where it is) instead of the exit being implemented,



(b)), the departure date and time of exit of the group, the departure of the group, type



(c)) date and time of arrival at the place of departure of the group events



(d)), a brief description of the clinical condition,



(e)) the working diagnosis,



f) description of the provided pre-hospital emergency care,



g) time and place of transfer of the patient to a medical facility, including

the identification of the recipient or the provider of the time and place of

their exit, if the patient has not been passed to the provider,



h) the name or names and surnames health workers who

pre-hospital emergency care provided.



A record of the trip, is passed to the destination provider of acute care,

where appropriate, the patient in a physical form, a copy of the record is archived in the

paper or electronic format for medical providers

the emergency services.



C. Identification and sorting tab contains:



and) patient's unique registration number (a combination of (a) identifying the

region and the serial number of the card),



(b) the degree of urgency of the patient's treatment),



(c) sorting out the patient, time)



(d)) the working diagnosis,



(e) the transfer of the patient odsunovému) time of the resource



(f) the transfer of the patient to the provider) time to acute care,



(g)) the kind of transport medical transport following the composition of the

the departure of the group according to the emergency medical service,



h) status of the vital functions, the evaluation of the patient, in particular in the

coma (GCS), blood pressure, and respiratory rate pulsová and graphically

illustrated location of injury,



I) record treatment, especially the administered medicines, used medical

resources, or performing a decontamination,



j) degree of urgency.



(D) the record of the mass expulsion. patients includes:



and) patient's unique registration number (a combination of a letter and an index

the numbers from the identification and sorting cards)



(b)), the redeployment of priority



(c) the transfer of the patient odsunovému) time of the resource.



11. DOCUMENTATION of NURSING CARE



A. record of nursing care includes:



Nursing medical history of the patient) and evaluation of the health status of

the patient,



(b)) the nursing plan, in which shall be entered:



1. Description of the nursing problem the patient or the determination of

Nursing diagnoses,




2. determination of implied nursing activities and performances, including

the record of their implementation and the lessons of the patient; Depending on the nature

Nursing performance shall indicate whether or not the time of its implementation,



3. the assessment provided to the nursing care and ongoing changes in

the nursing plan



(c)) ongoing records of the health condition of the patient, on surrender

information and guidance to the patient,



(d) nursing a layoff or translation) a report with recommendations to the

For more nursing care, which shall, in particular, summary information about the

provided nursing care including time information; can contain

other recommendations in nursing procedures; Nursing translation

the message is processed only if it is in advance of a planned hospitalisation

or location to another medical facility or equipment

social services.



(B). The scope of individual content components of nursing record

care in accordance with section and letters and) to d) can the provider of health services

Customize character provided nursing care, usually if

the total period of its duration in the same patient does not exceed 3 days.



12. The AUTOPSY PROTOCOL



A. autopsy report contains:



and the autopsy protocol number)



(b)) the identification of the deceased, to the extent provided in § 1 (1). 1

(a). (b)), if known,



(c)) the place, date and time of death, if known,



(d) the name or names), surname and title of health workers

participating in the autopsy,



e) start date and time of the autopsy,



(f)) of an anamnestic data and information about significant circumstances

related to the death, if known,



(g)), clinical diagnosis of the attending physician or the doctor performing the

inspection of the body of the deceased,



h) write about the autopsy carried out structured



1. external examination of the body of the deceased, description



2. internal tour with macroscopic description of the award of each

organs of body cavities,



3. information on the completion of the collection of biological material to other

testing; written result of these examinations is an integral part of the

the Protocol,



I) record of the mandatory reports.



The Protocol will connect to told the part (B) of the deceased, inspection sheet

a copy of the order to transport the body of the deceased from the autopsy and the original of the accompanying

worksheet for autopsy.



B. in the case of pathological-anatomical dissection is also part of the autopsy

autopsy protocol diagnosis divided on:



1. the basic disease



2. complications of the disease,



3. the immediate cause of death,



4. secondary pathological findings.



C. in the case of medical autopsies are also part of the autopsy protocol



and autopsy diagnosis divided on):



1. the underlying disease or injury,



2. the immediate cause of death,



(b)) identification of other people present at the autopsy, to the extent a name,

where appropriate, the name and surname; for other persons present shall also

work or status and the reason for the presence of.



13. the cover SHEET to



A. passport to autopsy contains:



and) identification



1. the provider whose doctor inspected the body of the zamřelého, in

extent provided in § 1 (1). 1 (b). and)



2. the inspection body in the doctor's range name or

name and surname,



3. the deceased in the range name or names, first and last name, social security number,

date of birth, social security number, if it is not allocated,



(b) the date and time of death), and even an estimate,



(c)) date and time of the inspection body,



(d)), the proposed type of autopsy to be performed.



The cover sheet shall bear the signature of the doctor who carried out the inspection body

zamřelého and stamp of the provider.



(B). the accompanying letter to the pathological-anatomical autopsy also contains:



and clinical diagnosis),



1. the basic disease



2. the immediate cause of death,



3. complications



(b)) of an anamnestic data, particularly information about cardiac events, diseases,

operations, blood transfusion or plasma,



(c) a brief description of the course of the disease), which was the cause of death,



(d) a description of the treatment (for example,), radiation therapy, treatment with antibiotics and such,

the application of radioisotopes),



(e) a record of the complaint) has been lodged,



(f) proposals to the special findings) when performing the autopsy, if it is to

clarification of the causes of death or the verification of therapeutic procedures is desirable.



(B). the accompanying letter to the pathological-anatomical autopsy children also contains:



and the information referred to in part (B)),



(b)) job or a profession of parents or profession,



(c)) of an anamnestic data, in particular



1. birth weight,



2. the birth of a spontaneous or operational,



3. kříšení after birth,



4. the indication of a multiple pregnancy,



5. the nutrition of the newborn (breastfeeding, artificial nutrition),



6. information on the number, age and State of health of siblings



7. information on previous fractures, diseases, surgery, blood transfusion or

plasma,



8. the completion of the vaccination.



D. passport to health the autopsy also contains:



and) instead of finding the body and its description, including details of the findings in the area of the body

(for example, medicinal products, medical devices, medicine bottles

fluid, electrical or gas appliances, animals),



(b)) the data on external factors having a bearing on the body (for example, temperature

environment, wind, moisture, direct light of the Sun, fire),



(c) a description of the body position before) by the intervention of emergency medical services,



d) details of the clothing (for example, left in its original state, rozstřiženo

-where, removed and, if so, which components),



e) description of the posthumous changes,



1. the spots; It shall be indicated on that part of the body and what (vytlačitelné as),



2. stiffness; It shall be indicated whether there was in the whole body or parts of the

the body, its strength,



3. a rectal temperature,



4. the rotting changes; It shall be indicated whether they are absent, the beginning or

Advanced, the presence of insects (out), the size of the larvae,



(f)) of the disease, if known,



(g) a description of the problem) preceding the death, if known, where appropriate, an indication of the sudden

death,



h) a description of any external signs of violence,



even) an indication of the implementation of resuscitation (lay, extended)



j) indication of invasive intervention in the provision of ambulance

care (such as cannulation vein drainage of the chest),



to write about the announcement of the award), the body of the police of the Czech Republic according to the record

operator,



l) record to a body which is on instead of finding the body came as the first,

and it



1. exit the Group of emergency medical services,



2. the police of the Czech Republic,



3. Fire Brigade, or



4. any other person; in this case, their identification shall be recorded

the information, if known, to the extent the name or names,

the last name, or whether or not their relationship with a deceased person, and the contact

details.



Annex 2



THE PRINCIPLES FOR THE PRESERVATION OF MEDICAL RECORDS AND THE PROCEDURE FOR ITS

DECOMMISSIONING AND DESTRUCTION AFTER THE EXPIRY OF THE RETENTION PERIOD



Article. 1



(1) withdrawal of medical records means the assessment and

the planned selection of medical documentation that is still for

provision of health services. When this selection is

Determines whether the medical record will be after the expiry of the

preservation of the retired and designed to destroy.



(2) the decommissioning of the medical records in the assessment of the need to

carried out within the time limits specified by the provider, but no longer than once per 3

years for the entire complex of the provider.



(3) the assessment of the need for all health

documentation, for which the retention period has expired. No assessment of the facts

decisive for the expiry of the period laid down for the medical retention period

the documentation and assessment of the need for medical records cannot be

medical documentation.



(4) the Technical supervision of the assessment of the need for the Commission to

the assessment of the need for medical documentation (hereinafter referred to as "the Commission"),

that has at least 3 members. Members of the Commission, which appoints and dismisses the

the provider, are healthcare professionals.



(5) in the case of a provider that has less than 10 medical

workers or other professional workers, the Commission does not establish and

a proper assessment of the medical records referred to in paragraph 3 corresponds to the

the provider.



Article. 2



Medical records retention period is the time that is required to

medical documentation kept in the provider for the purpose of providing

health services. Before the deadline expires shall not be health

documentation destroyed.



Article. 3



(1) medical record is referred to reject the characters that

Express medical documentation for additional provision

health services and treatment medical documentation for a

the expiry of its retention.



(2) the knockout character



and) "with" refers to the medical documentation, which is after the expiry of the

preservation will propose to destroy,



(b)) "in" indicates that the medical documentation whose value cannot be

the time when the specified; for these medical records

occurs after the expiry of the retention periods referred to in annex 3 to this

to assess the need for the Ordinance; part of the medical records already

unnecessary for the next delivery of health services is proposing to

disposal and destruction.



(3) the medical records retention period may be extended,


at least 5 years, if the medical record or part thereof

continue to be necessary to ensure the provision of health services.



Article. 4



(1) medical record according to the indicate reject characters

divide into groups of "V" and "S" to the group.



(2) the medical records of the group "in the" examine the head medical

a worker of the relevant Department of the medical equipment that

medical documentation leads, or by a designated health care professional

(hereinafter referred to as "designated health professional"), which will be designed

to be scrapped and which parts will be extended retention period. In the case of

health care professional providing health services, private

on behalf of, the assessment of the health professional.



Article. 5



(1) an authorized health care professional shall draw up a proposal for the decommissioning of

medical documentation that contains the identification data

provider, including the workplace, if his medical

equipment, so divided, identification of designated medical

the worker who drew up the proposal.



(2) the proposal for the disposal of medical documentation list

the medical records to be scrapped. At the end of the list shall indicate the

medical records with a single-elimination with the "in" with the proposal to its

the breakdown between the portion proposed to be scrapped and for the part which increases the time

preservation.



(3) a proposal for the disposal of medical documentation signed by an authorized

a health care professional.



(4) the provider, the originator of the governed under the law on

archival science ^ 11), shall forward the draft on the disposal of the medical records

together with a list of medical documentation to the disposal of the archive

the registered office of the provider, where appropriate, of the seat of his workplace,

If this workstation processor design, to assess and to perform

selection of archival materials outside the discarding of the proceedings.



(5) The archive after examining the list of medical records

designed to weed out and after a selection of archival documents outside of discarding

control passes to the Protocol for the selection of public records excluding discarding

proceedings (hereinafter referred to as the "Protocol on the selection of archival documents") provider.

The Protocol for the selection of public records contains an inventory of medical records

or parts thereof, that have been selected for archival documents and that

the provider shall forward to the relevant archives for inclusion in the register

the records within the time limit laid down; If the archive does not select the

inclusion in the register public records no medical documentation or

any part of it, in the selection of public records indicate this

the fact.



(6) the provider edits the list of medical records to be scrapped

According to the result of the selection of the records outside the discarding of proceedings

the appropriate archive and a customized list of passes together with a proposal on the

disposal of medical documentation and selection of public records

Commission under article 4(2). 1 (1). 4, if established, for consideration and confirmation.



Article. 6



(1) the Commission shall assess the draft on the disposal of the medical records and confirm

It will propose that, where appropriate, medical documentation should be

to preserve and extend the retention period. In doing so, shall take into account the results of the

the selection of the records carried out outside the discarding of the proceedings. The proposal shall provide a

the provider.



(2) the medical records discarded in the group "S" must be destroyed.

The destruction of medical records means the depreciation in such a

way as to prevent reconstruction and its identification

the content.



Article. 7



Pursuant to this annex shall be applied, mutatis mutandis, in the case of health

disposal documentation for the competent authority, that

medical documentation according to the law on health services took over the

the fact that a member of the Commission, which appoints and dismisses the competent administrative

the authority is at least one doctor, who also carries out activities authorized

a health care professional.



Annex 3



RETENTION PERIOD THE MEDICAL RECORDS OR PARTS THEREOF



1. the health care provided by the authorising service provider in the field of

General practical medicine, in the field of practical medicine for children and

Puppy, dentistry or in the field of gynaecology and obstetrics-S



10 years since the change of a registered provider, or 10 years from the death of

the patient's



2. other ambulatory care-with



5 years after the last examination of the patient



3. Dispensary care-in



and 10 years from decommissioning) of a patient from a dispensary care or termination of this

care, or 10 years from the death of a patient,



(b)) 100 years from the date of birth of the patient's dialyzovaného, or 10 years from the death of

the patient,



(c)) 100 years from the date of birth of the patient, that is in accordance with other legal

prescription ^ 12) carrier of infectious disease or for 10 years from the death of

of the patient.



4. Healthcare provided in connection with the treatment of mental disorders and

behavior disorders, including health care provided in connection with

protective treatment-with



100 years from the date of birth of the patient, or 10 years from the death of a patient



5. Inpatient care-with



40 years after the last patient hospitalisation or 10 years from the death of a patient



6. Day care-with



15 years from the last supply day care or for 10 years from the death of

the patient's



7. The Spa sanatorium rehabilitation care-with



10 years after the end of the Spa sanatorium rehabilitation care



8. Occupational health services



and)-with



100 years from the date of birth of the patient with recognised occupational diseases or 10

years after his death, unless otherwise stated, the



(b))



15 years from the date of recognition of the risk of occupational disease nebo10 years from the death of

the patient, unless otherwise specified,



(c))-in



10 years from the termination of employment of a person carrying out this work, included by

the law on the protection of public health in the first or second category and

passing information on the development of health status at the time of performance of the work and

the characteristics of health demands of the work undertaken, including the

job category by factors of working conditions and the length of the

their exposure, and pass next to the appropriate provider

occupational health services, or 10 years from the death of this person,



(d))-in



15 years from the termination of employment of a person performing a risky work according to

the law on the protection of public health, if it is not otherwise stipulated, and

passing information on the development of health status at the time of performance of the work and

the characteristics of health demands of the work undertaken, including the

job category by factors of working conditions, their

the degree and the duration of their exposure, and pass next to the competent

providers of occupational health services, or 10 years from the death of this

of the person,



(e))-in



40 years from the termination of the employment of a person performing a risky work in

the meaning of other legislation ^ 13), if that other legislation

calls, and passing information on the development of health status at the time of the performance

work and health characteristics of the intensity of the work undertaken, including

placing job category by factors of working conditions,

their peace and the length of their exposure, and pass next to the competent

providers of occupational health services, or 10 years after the death of this

of the person,



(f))



for employee category and 14) at least ^ ^ reaching the age of 75 years, always

However, for at least 30 years after the end of work in the category of

And,



g)-in



30 years of work injury associated with hospitalizations of more than

5 calendar days or 10 years after the death of the person who has suffered such a

the injury;



10 years of other work-related accidents.



Letters and), b) and (g)) apply to medical documentation-led

the authorising service provider in the field of general practical medicine,

provider of occupational health service provider and the competent

assessment and recognition of occupational diseases; c) to (f))

on the medical documentation conducted by the occupational health provider

services.



9. Emergency medical service-with



a) record operator for at least 10 years from the last record



(b)) a record of the trip, 10 years from the emergency medical services,



(c)) on the intake of an audio recording of an emergency call or invitation to trip

emergency services 24 months of receipt of the invitation.



10. Pathological Anatomy and forensic medicine



and)-with



part B of the worksheet on the tour of the deceased, if a determination is made about the autopsy

or if there is no autopsy has been ordered, for 20 years from the death of,



(b))



autopsy report, including the inspection of part B of the worksheet of the deceased, the information

on the implementation and results of the biopsy examination, where appropriate, further

the related examination, 150 years from their date of issue,



(c))



requisition for biopsy or cytology examination of 10 years of implementation

examination.



11. Imaging-with



and the graphic or audio-visual recording) or another video recording

(for example, digital) 10 years after the last examination of the patient

related to the provision of health services and the verification of the conditions

the emergence of occupational diseases (risk of occupational disease) according to another

legislation for which the required record was made, if the

not a patient in the dispensary or other care for disease

tracked imaging method



b) information on the progress and outcome of the examination of the patient's imaging

by 10 years after handing over information to the provider that the examination


imaging method requested.



12. verification of new knowledge on a live human being using methods so far

in clinical practice, non-clinical investigation of medical

resources and clinical evaluation of medicinal products-in



and at least 15 years from) their new knowledge, authentication



(b)) for at least 30 years from the termination of the irradiation, if authentication

new knowledge used methods that are associated with radiation, including

yet non-methods in clinical practice and those exposures where there is no

direct health benefit for the person undergoing the exposure to physical



(c)) for at least 15 years after the end of the clinical investigation of a medical

resource,



(d)) of at least 15 years after the end of the clinical trial medicinal

of the product.



13. the prescriptions marked with a blue stripe and a copy-with



At least retain prescription provided for in other legal

Regulation governing the treatment of addictive substances ^ 15).



14. The results of laboratory and other auxiliary examination-with



5 years after the date of the examination.



15. The requisition-S



5 years after the examination; This refers to a provider that has provided

pull the health service.



16. A record of the filing of a blood product-in



30 years of the administration of the transfusion medicine, or 10 years from the death of the patient.



1) § 19 para. 1 of the law No. 258/2000 Coll., on the protection of public health, in

amended by Act No. 274/2003 Coll. and Act No. 392/2005 Coll.



2) for example, law No. 285/2002 Coll. on the donation, subscriptions and

transplantation of tissues and organs and on amendments to certain laws

(the Transplant Act), as subsequently amended, Act No. 373/2011

Coll. on the specific health services.



3) section 39 of Act No. 372/2011 Coll. on health services and conditions

their provision (law on health services).



4) § 10 para. 4 of law No. 359/1999 Coll. on social and legal protection of children,

as amended by Act No. 375/2011 Coll.



5) for example, Act No. 285/2002 Coll., as amended, the law

No. 258/2000 Coll., as amended.



6) Act 258/2000 Coll., as amended.



7) for example, Act 48/1997 Coll., on public health insurance, and about

amendments to some related laws, as amended

legislation, law No. 582/1991 Coll. on the Organization and implementation of social

security, as subsequently amended, Act No. 359/1999 Coll., in

as amended, the Act 273/2008 Coll., on the police of the Czech

Republic, as subsequently amended, Act No. 141/1961 Coll.

criminal procedure (code of criminal procedure), as amended,

Act 258/2000 Coll., as amended.



8) Act 373/2011 Coll., on specific health services.



9) Act 227/2000 Coll., on electronic signature, as amended

regulations.



10) § 31 para. 5 of law no 372/2011 Sb.



11) § 3 (1). 1 of the law No. 499/2004 Coll. on Archives and records service

and amending certain laws, as amended by Act No. 190/2009 Coll.



12) section 53 of Act No. 258/2000 Coll., on the protection of public health and amending

some related laws, as amended by Act No. 274/2003 Coll.



13) section 40 (a). b) of Act No. 258/2000 Coll., on the protection of public health and

amending certain related laws.



14) Decree No. 307/2002 Coll., on radiation protection, as amended by Decree No.

499/2005 Sb.



15) section 33 of Act No. 167/1998 Coll. on addictive substances and amending

certain other laws, as amended by Act No. 117/2000 Coll. and Act No.

362/2004 Sb.