diagnosis and records

[Amy2005]

When an elderly patient, transferred to a long-term care facility, wants to find out their diagnosis (that caused them to go into hospital emergency), unsure if the doctor saw them while in the hospital, how can the patient find out the diagnosis?

[Whispera, MSN, RN]

The diagnosis wasn't on the discharge papers? It should be. It's her right to have a copy of her chart if she wants it, but she might have to pay for it, and she'd have to request it in person or by mail, or her POA would have to do it.

But, if she went to the ER, and was evaluated there, she was seen by a doctor, and the diagnosis is always on the discharge papers....

[Amy2005]

Thanks. For the patient to request the chart/diagnosis - who to ask? Ask medical recoords? Sounds reasonable to send a letter.

[rachelgeorgina]

Shouldn't there have been a discharge letter that came from the ER with her?

Shouldn't the LTC facility that SENT her have received some sort of handover from the ER staff, lest a discharge letter/summary?

Shouldn't the patient have been informed of what was wrong with her when it was figured out? That, to me, is just poor practice and a sad flaw in the system - that medical staff failed to even inform the pt that they saw what was wrong with them.

[Amy2005]

Actually, this is a patient who went to ER from home, then was sent from ER to LTC. Such an abrupt change, no longer able to go back home, and asking

"what was the cause of the problem?" I don't know what the medical staff said or did not say re: informing this patient of their health condition. Maybe there is some information or a form that came from the hospital to the LTC? Will check.