The hospital file: what belongs in it, and how to stop losing pages

A hospital stay produces a lot of paper, very quickly, at the worst possible time. Reports arrive in a rush, the file moves from ward to ward, and the papers you need weeks later are the ones nobody thought to keep.

A little order during the stay saves a lot of trouble afterwards.

One folder for each stay

Start a new folder when the admission begins, and write the person’s name and the dates on the front. Keep everything from that stay in it. When it ends, the folder joins the rest of that person’s records.

What belongs in it

• Admission papers and consent forms, with the dates.
• The doctors’ notes and advice you were given, or your own notes of what they said.
• Lab reports and scans done during the stay.
• The medicine chart or list of what was given.
• Bills, receipts and approvals, including every payment slip.
• The discharge summary.

The discharge summary matters most

The discharge summary is the hospital’s account of why the person was admitted, what was found and done, the medicines at discharge and what to do next. It is the paper a new doctor will want first, and the one an insurer will ask for.

Before you leave, check that it carries the person’s name and the dates, and read it. If something looks wrong, such as a wrong name or a medicine you don’t recognise, ask the hospital before you go home, not weeks later.

Ask for the final bill and the reports at discharge too. Collecting them later is harder.

Copy before you hand over the originals

Insurers and employers often ask for original papers. Before you send any, photograph every page, or photocopy it, and note what you sent and when. If a paper is lost on its way, you have a copy and a record.

Keep it findable

When you get home, put the folder with that person’s other records, and photograph the pages you don’t yet have on your phone. Name each photo with the person, the hospital and the date, so a search finds it in seconds.

Kinsu is an Android app that does this: you save each page as a photo or file, choose whose it is, and search by name, doctor or tag. It keeps the records on your phone, encrypted. It doesn’t send them to the hospital or an insurer, so it complements the paper file and doesn’t replace the originals.

Before the next admission

Keep a small “go folder” ready: an up-to-date medicine list, the latest reports for the main condition, insurance details and an emergency contact. If an admission comes suddenly, you’re ready.