The Electronic Health Record (EHR), as described in the Decree of the President of the Council of Ministers of 29 September 2015, n. 178, Regulation on electronic health records, contains the patient's clinical history represented by a set of data and documents. Among these, some are - by law - mandatory and are part of the so-called "minimum core", while others are supplementary documents and serve to enrich the EHR, but remain optional and depend on the choices made by the regional institutions and the level of maturation of the digitization process of individual documents produced by hospitals.
The minimum core of the Electronic Health Record
The minimum core of the data and documents in the EHR consists of:
- identification and administrative data of the patient;
- reports;
- Medical Emergency Reports;
- Hospital discharge letters;
- Patient Summary;
- pharmaceutical dossier;
- consent or refusal to donate organs and tissues.
The Patient Summary (PS)
Of particular importance is the Patient Summary (PS), which can be considered as the patient's "health identity card". The document is drawn up and updated by the General Practitioner (GP) or the Pediatrician and guarantees continuity and a better quality of care, especially in emergency situations or when out of own region. It contains, in addition to the identification data of the patient and his doctor, all the clinical information describing the patient's status such as, for example, the list of relevant problems, diagnoses, allergies, pharmacological therapies for any chronic pathologies and all the essential indications to guarantee patient care. In the event of a change of the GP / Pediatrician who is treating the patient, the new doctor will keep the PS previously created or draw up a new one.
Optional data and documents in the Electronic Health Record (EHR)
The supplementary data and documents of the EHR, and therefore not mandatory, are:
- prescriptions (specialist, pharmaceutical, etc.);
- reservations (specialist, hospitalization, etc.).
- medical records;
- health balances;
- home care: form, program and clinical-assistance record;
- diagnostic-therapeutic plans;
- residential and semi-residential care: multidimensional evaluation form;
- drug delivery;
- vaccinations;
- specialist assistance services;
- urgent emergency services (118 and first aid);
- inpatient hospital care services;
- medical certificates;
- personal Health Record;
- reports relating to the services provided by the continuity of care service;
- self-certifications;
- participation in clinical trials;
- exemptions;
- prosthetic assistance services;
- data to support telemonitoring activities;
- data to support the integrated management of diagnostic-therapeutic pathways;
- other documents relevant to the patient's care pathways.
The Personal Health Record
Among these documents, the personal health record is a reserved section within the EHR in which the assisted person can, in complete autonomy and according to the access methods defined at the regional level, add all the data and documents that he deems most appropriate, concerning his own treatment path even outside the National Health Service (NHS). This information is, of course, distinct from the others as it is not certified by the NHS operators and the client can choose whether and to whom to make it visible.
All these elements constitute the Electronic Health Record of the citizen and allow to have a clear and exhaustive picture of the patient's clinical history, facilitating both ordinary care (all data are associated with the EHR, reachable at any time and in any place, avoiding having to carry paper documentation) and emergency documentation (allowing, for example, an emergency room doctor to have the information necessary for a correct intervention in emergency situations).