Section 1: Information for guests.

A medical file is created for each patient hospitalised in a public or private health establishment. This file contains at least the following elements, classified as follows :

1° Formalised information collected during outpatient consultations provided in the establishment, during reception in the emergency department or at the time of admission and during the hospital stay, and in particular :

a) The letter from the doctor who initiated the consultation or, in the event of admission, the liaison letter provided for in Article R. 1112-1-1 ;

b) The reasons for hospitalisation ;

c) The search for antecedents and risk factors;

d) The conclusions of the initial clinical assessment;

e) The type of care planned and the prescriptions made on admission;

f) The nature of the care provided and the prescriptions drawn up during the outpatient consultation or the visit to the emergency department;

g) Information relating to the care provided during hospitalisation: clinical condition, care received, para-clinical examinations, particularly imaging examinations;

h) Information on the medical approach adopted under the conditions provided for in Article L. 1111-4 ;

i) The anaesthetic record;

j) The operation or delivery report;

k) The patient's written consent in situations where consent is required in this form by law or regulation;

l) Details of transfusion procedures performed on the patient and, where applicable, a copy of the transfusion incident form referred to in the second paragraph of Article R. 1221-40;

m) Information relating to the medical prescription, its execution and additional examinations;

n) The nursing care record or, failing this, information relating to nursing care;

o) Information relating to care provided by other healthcare professionals;

p) Correspondence exchanged between healthcare professionals;

q) The advance directives referred to in article L. 1111-11 or, where applicable, a mention of their existence and the contact details of the person who holds them.

2° Formalised information drawn up at the end of the stay. This includes in particular

a) The discharge liaison letter provided for in article R. 1112-1-2;

b) The discharge prescription and duplicate discharge prescriptions;

c) The discharge arrangements (home, other facilities);

d) The nurse liaison sheet;

3° Information mentioning that it has been collected from or concerning third parties not involved in therapeutic care.

Only the information listed in 1° and 2° may be disclosed.