How to Organise the Transfer of an Elderly Person's Medical Records Between Doctors and Care Homes

When Maria's mother was transferred from hospital to a care home, the new staff discovered three days later that the elderly resident had been taking an anticoagulant that nobody had mentioned. The absence of a complete medication list could have led to dangerous interactions. This situation, unfortunately common, illustrates just how important accurate communication and thorough transfer of medical information truly are.

For families caring for an elderly person, organising a medical file can feel overwhelming, especially during times of transition: on discharge from hospital, when moving into a care home, or when home care begins. Yet a proper transfer of medical information is not merely a bureaucratic formality – it can mean the difference between safe care and avoidable health risks for your loved one.

In this practical guide, we will walk through the process of organising and transferring a medical file step by step, so that you and your family are fully prepared to ensure continuity of medical care, whatever the circumstances.

Contents

1. What medical documents should be included in an elderly person's file
2. Who holds the documents and where to find them
3. How to request and transfer the medical file to a care home or carer
4. Common mistakes families make when transferring information
5. The emergency medical summary: what it should contain
6. The elderly person's rights regarding their medical file and the role of a representative
7. Frequently asked questions

What medical documents should be included in an elderly person's file

A complete medical file for an elderly person should function like a detailed map of their health history. It is not simply about the most recent diagnosis, but about the full picture that allows any medical professional to quickly understand the situation of the person in their care.

The essential documents a family should gather include:

• The GP's medical record – contains the history of consultations, vaccinations, diagnosed chronic conditions and their progression over time
• Discharge letters – detailed summaries of each hospital admission, including established diagnoses, treatments administered and recommendations upon discharge
• Active repeat prescriptions – the complete list of long-term medications, with exact doses and frequency of administration
• Recent investigation results – blood tests, imaging (X-rays, ultrasounds, CT, MRI), ECGs and other investigations from the past 6–12 months
• Specialist consultations – reports from specialist physicians (cardiologist, neurologist, diabetologist, etc.) with secondary diagnoses and specific recommendations
• Allergy documentation – a clear list of known drug or food allergies

Additional important documents

Beyond the core documents, there are others that may be crucial in specific situations: the certificate of disability or dependency classification, geriatric assessment reports, documentation relating to implanted medical devices (pacemaker, prostheses), and, not least, any advance directives or special powers of attorney for medical decisions.

Who holds the documents and where to find them

One of the most common points of confusion for families is misunderstanding who actually owns the medical documents. Legally, the patient is the owner of their own medical information, but the physical or electronic documents are held by healthcare providers – which means you are entitled to copies, not to the originals held in the doctor's records.

Here is where the necessary documents are typically found:

• The GP – holds the patient's record with the complete history, issued repeat prescriptions and referrals to specialists
• Hospitals – hold discharge letters, clinical observation charts and the results of investigations carried out during admissions
• Specialist clinics and private practices – hold the reports from specialist consultations and the results of investigations carried out there
• Laboratories and imaging centres – can provide copies of test results and investigations, usually in physical or digital format
• The patient's personal file – elderly people or their families often keep copies of important documents at home, in a folder or binder

Documents in electronic format

An increasing number of healthcare facilities offer access to medical documents through online platforms or dedicated applications. It is worth checking whether the elderly person's GP or the hospitals where they have been admitted offer this facility – it can significantly simplify the process of accessing and transferring information.

How to request and transfer the medical file to a care home or carer

The actual transfer of a medical file requires an organised approach and clear communication with all parties involved. The first step is to identify exactly what information is needed in the new care setting and to understand the specific requirements of the care home or professional carer.

The step-by-step process should look as follows:

1. Contact the care home or care service to find out precisely which documents they require and in what format (copies, originals, electronic format)
2. Draft a written request to each healthcare provider (GP, hospital, clinic) asking for copies of the relevant documents – state the purpose (transfer of care) and the time period for which you are requesting information
3. Attend in person at the GP's or hospital's registration desk with the patient's identity document (or your own, if you are their legal representative) and, if necessary, a written authorisation from the elderly person
4. Pay any applicable fees for photocopies or CDs containing imaging investigations – these vary but are generally modest
5. Check the completeness of the documents received before passing them on – make sure nothing essential is missing
6. Hand over the documents to the care home or carer together with a checklist of everything provided, keeping copies for yourself

Communication between doctors

In more complex situations, it is advisable to facilitate a direct conversation between the elderly person's GP and the care home's doctor or the medical coordinator of the care service. This professional dialogue can clarify subtle aspects of treatment that do not always come through clearly in written documents.

Common mistakes families make when transferring information

Even with the best of intentions, families often make errors that can undermine continuity of care. Being aware of these common pitfalls can help you avoid them.

The most frequently encountered mistakes include:

• Omitting supplementary medications – vitamins, supplements or medications taken "only when needed" are often forgotten, yet they may interact with prescribed treatments
• Missing secondary diagnoses – focusing only on the primary condition (dementia, for example) and overlooking other medical issues such as diabetes, hypertension or heart conditions
• Incomplete allergy information – mentioning only severe allergies and omitting moderate adverse reactions to certain medications
• Absence of social and functional context – transferring only medical information without mentioning important aspects relating to mobility, diet, behaviour or social relationships
• Outdated documents – passing on information that no longer reflects the elderly person's current state of health
• Missing information about medical devices – failing to mention prostheses, glasses, hearing aids or implanted devices

When chronology matters

Another subtle but important mistake is presenting information without a clear timeline. Understanding how a condition has progressed over time can be crucial for adapting treatment. It is therefore helpful to organise documents chronologically and to mark key dates clearly.

The emergency medical summary: what it should contain

Alongside the full medical file, every family should have ready to hand an emergency medical summary – a document of no more than 1–2 pages containing the vital information needed in the event of a medical emergency. This summary can save lives when your elderly relative is taken ill and needs to be assessed quickly by an ambulance crew or in accident and emergency.

An effective emergency medical summary should include:

• Full identification details – name, date of birth, national identification number, address, blood group
• Emergency contact – the name and telephone numbers of close family members
• Primary chronic conditions – the major diagnoses listed in order of importance (for example: heart failure, type 2 diabetes, Alzheimer's disease)
• Complete list of current medications – with both brand names and generic names (INN), exact doses and times of administration
• Drug allergies and intolerances – including the type of reaction (rash, anaphylactic shock, etc.)
• Relevant surgical history – major procedures from recent years
• Medical devices – pacemaker, stent, prostheses, etc.
• GP and principal specialists – with contact details

Where to keep the emergency medical summary

This document should exist in multiple copies: one in the elderly person's wallet or handbag, one on the fridge at home, one with the primary emergency contact and one at the care home or with the carer. There are also dedicated mobile applications in which you can store this information, making it quickly accessible in an emergency.

The elderly person's rights regarding their medical file and the role of a representative

It is essential to understand that, from a legal standpoint, every person has the full right to information about their own health, regardless of age or cognitive state, as long as they have not been legally declared incapacitated. This means that, in principle, your elderly relative must give their consent for their medical data to be shared with other individuals or institutions.

The rights of the elderly patient include:

• Access to their complete personal medical record, with the exception of the doctor's subjective notes
• Obtaining copies of medical documents (at cost for copying)
• Correction of any errors in the medical record
• Confidentiality of medical information from third parties, including family members, without explicit consent
• The right to decide who has access to their medical information

The role of the legal representative or family members

When an elderly person finds it difficult to manage medical matters independently due to dementia, serious illness or other limitations, a family member may act on their behalf. However, from a legal standpoint, this requires either a written power of attorney from the elderly person (provided they still have legal capacity), or a court order placing them under guardianship and appointing a guardian (in more serious cases).

Without these legal documents, doctors and hospitals may refuse to share medical information directly with family members, citing confidentiality. It is therefore advisable to arrange these legal matters in good time, ideally while the elderly person is still easily able to sign a power of attorney.

Advance directives and medical powers of attorney

Still within the context of rights and representation, it is worth discussing as a family the matter of advance directives – documents through which the elderly person expresses in advance their preferences regarding certain medical treatments for situations in which they will no longer be able to communicate. These directives form part of the medical file and should be passed on to any institution taking over their care.

Frequently asked questions

How long does it take to obtain medical documents from a doctor or hospital?

As a general rule, a GP can provide copies of documents within 1–3 working days. Hospitals may take between 5–10 working days for extracts from clinical observation charts. In urgent situations, the process can be expedited if you explain the need.

Do I have to pay for copies of medical documents?

Yes, modest fees are generally charged for photocopies (a few RON per page) or for CDs containing imaging investigations (10–30 RON). However, the first copy of a hospital discharge letter is provided free of charge under the law.

What should I do if the elderly person refuses to share their medical information with the family?

Respect your loved one's wishes, but try to have an open conversation about the importance of this information for their safety. If the refusal persists and there are serious concerns about their decision-making capacity, it may be necessary to consult a solicitor specialising in family law.

Can a care home refuse to admit an elderly person if their medical file is incomplete?

Yes, most care homes are entitled to make admission conditional on the presentation of a minimum required medical file in order to assess whether they can provide appropriate care. It is in everyone's interest for there to be complete transparency about the person's state of health.

How often should an elderly person's medical file be updated?

The file should be updated whenever significant changes occur: new diagnoses, changes to treatment, hospital admissions or deterioration in general health. The emergency medical summary is worth reviewing every 3–6 months or whenever medication changes.

Can I send medical documents by email, or must I deliver them in person?

You can send medical documents by email if both the sender and the recipient agree to this format, but ensure you use secure channels. For sensitive information, many institutions prefer personal delivery or purpose-built secure platforms.

Organising and properly transferring an elderly person's medical file may seem like a complex administrative task, but it is an essential act of care that ensures continuity and quality of treatment. By investing time now in gathering and organising this information, you give your loved one the assurance that their medical needs will be understood and respected in any situation. If you need support with this process, do not hesitate to speak with the GP or a specialist in elderly care – they are there to guide you.

This article is for informational purposes only and does not replace medical advice. For specific situations, please consult a specialist.