Conformément au Code de la santé publique, les médecins sont tenus d’ouvrir un dossier médical pour chaque patient, de le mettre à jour et de le conserver. Un dossier qui peut être consulté par le patient qui en fait la demande. Concrètement, ce dossier médical doit comporter les éléments actualisés nécessaires aux décisions diagnostiques et thérapeutiques du médecin. Mais lorsque le patient consulte un médecin remplaçant, ce dernier doit-il créer un nouveau dossier médical ?
La question s’est posée dans l’affaire récente suivante. Une patiente avait consulté un dermatologue afin de subir un peeling du visage. Ce dernier avait agi en tant que médecin remplaçant de son dermatologue habituel. À la suite de cet acte médical, la patiente, qui avait présenté des sensations de brûlures et des lésions, avait saisi la justice en vue d’engager la responsabilité du dermatologue remplaçant et d’obtenir une indemnisation. Dans le cadre de ce litige, elle lui reprochait notamment de ne pas avoir constitué de dossier médical.
Saisie de l’affaire, la Cour de cassation a estimé que le médecin remplaçant n’avait pas commis de faute. En effet, ce dernier avait consigné les informations essentielles relatives au suivi de la patiente dans le dossier médical principal tenu par le dermatologue remplacé mais aussi dans une lettre retraçant l’historique du suivi médical et les ordonnances fournies, reconstituant ainsi l’intégralité du parcours thérapeutique de la patiente. Des documents que la patiente avait bien eu en sa possession.
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