In compliance with the ethical rules applicable to them as well as articles L. 1110-4, L. 1470-5 and L. 1111-2, each healthcare professional, regardless of how or where they practice, must enter into the shared medical record, at the time of each procedure or consultation, the diagnostic and therapeutic elements necessary for the coordination of the care of the person being cared for, the list of which is set by order of the minister in charge of health. Each professional must also send these documents by secure messaging to the attending doctor, the prescribing doctor if applicable, any professional whose involvement in the patient’s care seems relevant and the patient. During a patient’s stay in a healthcare facility, authorised healthcare professionals must enter a summary of the main elements relating to this stay in the shared medical record, in compliance with the obligations defined by the Haute Autorité de Santé. The attending doctor referred to in article L. 162-5-3 of the Social Security Code must periodically, and at least once a year, provide a summary, the content of which is defined by the Haute Autorité de santé. The healthcare professional may not be held liable in the event of a dispute relating to ignorance of information which was hidden from him/her in the shared medical record and of which he/she could not legitimately have been aware at the time.
The data required for the coordination of care resulting from the reimbursement or assumption of responsibility procedures held by the organisation to which each health insurance beneficiary is affiliated is included in the shared medical record.
The shared medical record also includes sections relating to organ or tissue donation, the advance directives mentioned in article L. 1111-11 of the present code and the trusted support person mentioned in article L. 1111-6.
Certain information may be made inaccessible by the holder of the shared medical record. If the latter is an adult subject to a legal protection measure with representation relating to the person and is not capable of expressing his or her wishes, the decision is taken by the person responsible for the protection measure, taking account of his or her opinion.