Medical Documents from Abroad: Which to Keep Forever
Learn which medical documents obtained abroad are worth keeping forever, how to properly prepare them for use in Ukraine or abroad, and what legal aspects to consider.
Why Keep Medical Documents from Abroad?
After treatment or examination abroad, you will likely receive a significant amount of medical documentation. This can include lab results, discharge summaries, operative reports, doctor's recommendations, and more. The question often arises: should these documents be kept, and if so, which ones and for how long?
Keeping medical documentation obtained abroad is important for several reasons. Firstly, it may be needed for further treatment in Ukraine or another country. Secondly, some documents might be necessary for insurance claims or legal purposes. Thirdly, it's valuable information about your health that could be useful in unforeseen situations.
This issue becomes particularly relevant for those planning to immigrate, work, or study abroad. In such cases, translations of medical documents, notarization, apostille, or consular legalization might be required, depending on the destination country's requirements.
Which Documents Are Most Important?
Not all medical documents have equal value for long-term storage. The most crucial are those containing key information about diagnosis, treatment, and prognosis.
Operative Reports: These provide a detailed description of a surgical procedure, including the date, the course of the operation, materials used, and any complications. This information is critical for future treatment and health assessments.
Histology Results: Histology is the microscopic examination of tissues, often used to diagnose cancer and other serious diseases. Histology results are definitive and can influence the choice of further therapy.
Information on Implants and Serial Numbers: If you have had implants (e.g., joint replacements, pacemakers, dental implants), keep all information about them, including the manufacturer, model, and serial number. This may be necessary for warranty service, replacement, or in case of issues.
Discharge Summaries: This is a summary document containing information about the diagnosis, treatment received, test results, and recommendations. Summaries from reputable foreign clinics carry significant weight.
Results of Complex Diagnostic Procedures: For example, results from MRI, CT, PET-CT, endoscopy, or biopsy that contain important data for diagnosis or clarification.
Information on Chronic Conditions and Allergies: If you have chronic conditions or allergies, keep documents confirming them, as well as information about treatments and reactions.
Legal Aspects and Translations
When using medical documents abroad or in Ukraine, particularly when submitting them to official institutions such as insurance companies, government authorities, or healthcare providers, an official translation may be required. The translation should meet the requirements of the institution receiving the document and accurately convey the content of the original.
Depending on the country, the type of document, and the purpose for which it will be used, a notarized translation, certification of the translator's signature, or another form of document authentication may be required. Foreign documents submitted in Ukraine or another country may also need an apostille or consular legalization. However, these procedures are not universally required: the applicable requirements depend on the country, the type of document, the purpose of submission, and whether an international treaty applies between the relevant states. Therefore, it is advisable to check the current requirements with the institution to which the document will be submitted.
Ukrainian legislation guarantees patients the right to receive accurate and complete information about their health and to access the relevant medical records. This is provided, in particular, by Article 39 of the Fundamentals of Ukrainian Legislation on Health Care. At the same time, Ukrainian law does not establish a general rule that medical records are the “property of the patient.” The procedure for obtaining and using documents issued by foreign healthcare providers may depend on the requirements of the institution to which the documents are submitted.
The laws of other countries also provide mechanisms allowing patients to access their medical information. For example, the General Data Protection Regulation (GDPR) applies in EU countries and regulates the processing of personal data, including health data. The right of access to personal data may cover medical information, although the scope and procedure for exercising this right are determined by the GDPR and the national legislation of the relevant country.
How Long to Keep Medical Documents?
The retention period for medical documents depends on their type, the legislation of the country where they were obtained, and your personal needs. Generally, the recommendations are as follows:
- Documents related to chronic conditions or past surgeries: Keep for life.
- Histology results: Keep for life.
- Information on implants: Keep until information about their replacement or removal is obtained.
- Discharge summaries and test results: Recommended to keep for at least 5-10 years, and for particularly important ones – for life.
Some countries have legal requirements for the retention periods of medical documentation by healthcare facilities. For instance, in the UK, hospitals are obliged to keep patient records for a certain period, which can vary but often is 8 years after the last visit or the patient's death. In the USA, the periods can be even longer, depending on the state and the type of medical facility.
Organizing Storage
To keep your medical documents organized, follow these tips:
- Create a dedicated folder: Set up a physical or digital folder for all medical documents obtained abroad.
- Systematize: Group documents by type (surgeries, lab tests, discharge summaries) or by date.
- Make copies: Keep digital copies (scans or photos) of all important documents in cloud storage or on an external hard drive. This will ensure access even if the original is lost.
- Translate as needed: If you plan to use the documents in another country, arrange for their translation and legalization in advance.
Keeping medical documentation is an investment in your future health and peace of mind. Do not ignore this important part of your medical history.