Clinic forms and documents

Besides the consent documents themselves, a visit generates administrative paperwork: the receipt for the papers you took at check-in, the receipt when you give them back, the self-declaration attached to the agreement, and the report when a patient refuses to sign. Med keeps this set as real forms — the same documents your clinic used before, filled in from what it already knows about the patient, the visit and you.

This page covers how those forms work. The consent documents follow the same mechanics and are described in Running a consent session.

Which forms your clinic gets

Two things decide the set:

Your facility type — Private clinic, Hospital, Dental practice or Psychiatric hospital, set once under Medical facility in the settings (gear icon in the Hub header). Handover, return and refusal paperwork exist in both a clinic and a hospital version, and Med picks the right one for you. A dental practice and a psychiatric hospital also get their specialty’s own agreement, annex and refusal forms in place of the general ones.
The procedure’s family — the medical family of the procedure in your catalogue decides whether a visit gets the general forms or a specialty’s own.
The stage of the visit — Med only offers a form where it belongs.

Stage	Form	How it is completed	How often
Admission	Document handover report — the receipt for the patient’s ID papers, health card or medical file taken into the clinic’s keeping	By hand, pre-filled from the patient record and your clinic identity	Once per admission episode, not at every visit
Consent	Informed patient agreement	Filled from the visit, then reviewed by you	Every consent consultation
Consent	Pathology consent annex	Filled from the visit and your clinic’s approved wording	When the procedure calls for it
Consent	Self-declaration, annex to the agreement	By hand	Every consent consultation
Refusal	Treatment refusal declaration — the patient’s own signed refusal	Filled from the visit, then reviewed by you	Only when the patient refuses treatment
Refusal	Refusal-to-sign report — records that the patient refused to sign, signed by the staff member and two witnesses	By hand	Only when needed
Discharge	Document return report — the receipt that the patient’s papers were given back	By hand	Once, at discharge

The discharge stage appears only once an admission episode exists, and the refusal stage only once a refusal has been detected, a doctor has marked a visit refused, or refusal paperwork already exists.

The library also carries paperwork that is drawn up by staff rather than signed by the patient — for example the Hostile-attitude report, the Relationship termination notice and the Patient referral notice — and, for a psychiatric hospital, admission reports such as the Emergency admission report. These are clinical records: Med lists them on the visit as “Clinical records - not signed”, “Filed on this visit. They are not part of the consent the patient signs.”

Where you start a form

There are three ways in:

The patient’s Documents tab. Its To complete list gives the action for each outstanding form — Hand over documents for the admission handover, Discharge for the return receipt, Create refusal document for refusal paperwork, Create document for other hand-filled forms. Paperwork you start while a visit is open is listed under that visit.
The visit itself. A visit that is still open lets you add a document to it: “The document is filed against this visit and joins the list above.” Med only offers forms the visit can actually use.
Practice documents → Patient forms, the clinic’s forms library: “Search and fill the forms available for a patient.” Pick a form, then Use this form, then the patient (or register a new one). If that patient has a consultation in progress, Med asks Where should this go? — File it under this consultation, which joins it to the visit’s documents and signing, or File it on the patient’s record only. The library shows only when your clinic has the practice documents module.

The appointment page also shows an amber banner while the admission handover is unsigned for that visit, with the Hand over documents button in it. If a copy of the form already exists, Med warns you — “This document already exists for this patient:” — and asks you to continue only if you mean to create a new copy for this visit.

Completing a form by hand

The create screen pre-fills what it can from the patient record and your clinic identity, with links to Edit my identity and Edit patient if something is wrong at the source. Every field the screen shows must be filled before Med creates the document (a checklist needs at least one tick), and Med says which ones are missing. A form with nothing to fill in says so: it is drawn up from the patient record and the consultation, so generate it and check the document.

Press Generate document. Med renders the document, tells you “… created.”, and takes you to the document page — at status Unsigned, ready to sign or to print.

Completing a form that Med filled in

Forms filled from the visit — the agreement, the pathology annex, the refusal declaration — arrive as a Draft with no printable file, behind the field review gate. Med lists anything the conversation did not supply, and Suggest from the clinic library offers passages from your approved content for a field. Where Med proposes library text for a field by itself, it is marked from the clinic library and waits for you to Keep or Discard it. When the fields are right, press The fields are correct - create the document and Med renders it.

This is the same gate described in Running a consent session; nothing prints before a clinician has confirmed the content.

Signing: on screen or on paper

Each document offers How will this document be signed?

On screen (with electronic seal) — “The patient signs on this screen. The document is sealed electronically and has legal value.” Med shows one signature box per signature the document prints. Depending on the form that can include:

the declarant — the patient, or the legal representative for a minor;
reception or medical staff;
the clinicians and witnesses the form names.

Tick “I have checked the identity data above together with the person signing.” and the confirmation that everyone named is signing in person, press Sign document, and Med produces the sealed PDF in the background.

Med refuses a signature it cannot stand behind, and says why:

a document that names the wrong person as the signer — the patient where a legal representative has to sign, or someone other than the person on file;
a minor, or an adult recorded as unable to consent, with no legal representative on file; and a patient with no date of birth or CNP, whose age is therefore unknown;
a copy that says the opposite of the visit’s decision to consent or refuse;
a document that changed after it was shown for signing — review the current version with the signer and sign again.

On paper — “Print the form, collect a handwritten signature, then photograph the signed pages.” The sequence is: download and print, collect the signature, then capture. See step 8 of the consent session for the capture rules; they are identical for all forms. Change how this is signed switches back to signing on screen.

Signed once per visit

A signed form is final for its visit. Ask for it again and Med tells you “… was already signed for this visit.” and opens the existing document instead of making a second one; the create action disappears from the patient’s To complete list.

What counts as the same visit:

the same appointment always does;
a form signed with no appointment attached counts within the visit window, so a visit that runs past midnight or is reopened the next day is still one visit;
a different appointment is a different visit, and the form is offered again.

Admission and discharge work per admission episode rather than per visit: handover is blocked while the episode is open, discharge once the episode is closed. Changing your facility type does not unlock either.

Downloading, and what format you get

Every form is produced as a document and normally converted to PDF, which is what the Download PDF button gives you. The Word version is available as Download Word, and becomes the main option when a PDF could not be produced. In that case Med says so plainly — “The PDF preview is temporarily unavailable. Download the filled Word document - it contains the full text.” — rather than leaving you with nothing.

What the PDF contains, in order of precedence: the captured scan if the document was signed on paper, otherwise the sealed signed PDF, otherwise the rendered preview.

Translations

Where a form supports them, Med produces informative translation annexes in Hungarian, English or German:

while a document is still being prepared, the preview has a Preview language switcher;
once a document is signed, the Translation annexes panel offers Generate translation per language, and a PDF to download when it is ready.

Which languages are on offer follows the visit: a consent session that declared no translation languages gets none. Paperwork that has no visit behind it — an admission or discharge receipt — offers all three.

An annex is never a signed document. The panel says it: “Informative translation only - the signed Romanian document is the legally binding version.”

Deleting a document

Only a Draft or Unsigned document can be deleted, from the document’s more-actions menu, and never while it is being signed. Med warns you exactly what goes: “This permanently removes the document and its downloaded files, together with every correction you made while reviewing the fields. A new document is generated from the conversation again - what you typed by hand does not come back.”

A signed document cannot be deleted. If a visit is missing a document it needs, Med holds the visit at Generate it again rather than letting you walk on to signing an incomplete set.

Limits worth knowing

Capture uploads: JPEG, PNG or WebP images, or a single PDF; up to 15 MB per file.
You must upload exactly as many pages as the printed document has. Med tells you the count it expects.
A capture is bound to one version of a document. Reprint if the document changed.
Signing runs once at a time: “Signing is already in progress.”
A clinic administrator viewing another doctor’s patient sees the paperwork read-only.

Where the visit’s file ends up

The patient’s Documents tab groups the paperwork into one dossier per visit, “from those that need action to those that are finished”. Each dossier lists the documents it requires with their state — prepared, not finished, or missing — and says whether it is complete. While the consultation is open, its documents read “Available once the consultation is finished.” — the work still belongs to the open visit, which is where you change it.

A complete dossier offers View archive, a preview of what it holds (signed on screen, signed on paper and scanned, translation annexes), and Download archive (.zip). “The archive can be downloaded once the dossier is complete.”

Contracts and regulations

With the practice documents module, the Practice documents section also holds Contracts — “Contracts with patients and staff, personalised with the facility’s details.” — and Regulations — “The facility’s internal rules. Not signed per patient.” Each document can be previewed as a PDF and downloaded as Word, with the facility’s legal identity filled in where the template names the facility. That identity — legal name, registered office, trade register number, fiscal code, and the sanitary authorisation number and date — is entered under Medical facility; what you leave blank stays blank in the template.

A clinic administrator can also Upload a document of the clinic’s own (Word or PDF, up to 25 MB), upload new versions of it, and Retire it — a retired document gives way to the model KlusAI supplies, and can be restored.