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At the end of a hospitalization, a visit or an exam, the patient has the right to his/her clinical documentation compiled by the health care professional.
In the case of hospitalization, standard or day hospital, a clinical chart is completed; at the end of a visit in the ambulatory care clinics, an ambulatory care clinical report is filled out; after a therapeutic procedure or diagnostic exam, a reference or clinical report is produced, and after an emergency room admission, an emergency room report is completed.
Questions? Niguarda answers
HOSPITALIZATION
> What documents will I be given when I am discharged?
Every patient will receive:
• A discharge report which describes what happened during hospitalisation, orders for treatment and medications at home, and schedules for follow up appointments.
• A nursing care plan which indicates patient’s needs and advice for eventual assistance at home.
• Any documentation which was brought by the patient to the hospital and turned in on admission.
> What is the patient chart?
“The means for communicating all anagraphical and clinical information which regards a patient for a single hospitalisation “ (Health Ministry 1992). It is an official legal document.
> Is it possible to consult my patient chart during hospitalisation?
Yes, in the presence of a health care provider.
> Is it possible to have a copy of my patient chart after discharge?
Radiology and pneumolgy reports and documentation will be given on a Cd-ROM support to guarantee a considerable saving to the patient;
certificazionisanitarie@ospedaleniguarda.it
AMBULATORY VISITS AND EXAMS
> What documents will I be given after a visit or exam in the ambulatory clinic?
After the visit the doctor will give you the written report which indicates the outcome of visit, orders from home, and eventual follow up appointments. It is important to keep this report and to bring it to any following visit. After a laboratory test or radiological exam the doctor will prepare a report with the readings of diagnostic studies. These reports can be picked up at:
Window for Exams Results (Sportello Ritiro Referti)
Souh Area, South Block
mon-fri: 8.00 a.m.-7.30 p.m. – sat: 8.00 a.m. -1.00 p.m.
Tel. 02 6444.7715
The request must be made by the patient or by a third party with written permission. A photo I.D. card of the patient and eventual third party, in original or in photocopy, must be brought.
Some exam results are sent directly to the diagnostic center where the exams were performed.
> And to request other health documentation?
The request for copies of of certificates of recovery, ambulatory care documentation, Emergency Room reports, reports from the Court Authority, workers’ compensation papers (INAIL), and radiodiagnostic images can be made using the same procedure as the request for the clinical chart.
> How much does it cost?
The service of photocopying of clinical documentation is chargeable, even for patients with exemption from health care fees. The cost is based on the number of pages of the clinical chart or documentation requested, and the cost of radiodiagnostic image reproduction is fixed per image.
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