Medical Records

A medical record is “diagnostic, treatment and care information” which aids doctors and other medical staff in treating you. A medical record must adhere to the Alberta Health Information Act. Many hospitals and clinics are controlled by the government. Thus, other records will only be accessible through Freedom of Information requests. For example, let us say you, assault staff, at a hospital and are injured at the hospital, but you are treated at that hospital. Your treatment and care information as a patient would be subject to the Health Information Act. Yet, any other personal information collected or created by security staff due to the incident, would be subject to the Freedom of Information access rules.

The medical record informs a doctor of your medical history, consultations, tests run, any treatments given, and their results. In the hospital, your medical record contains information, such as results of x-rays, laboratory tests and other tests run, as well as observations, treatments and any medication given. A detailed chart is important for informing others involved in your care of what happened before their involvement.

The information in the medical record belongs to you. However, the actual medical record belongs to the person or institution who originally created and maintained it (such as a hospital or the doctor). So, you do not own the record, nor do you have the legal right to remove it from the doctor’s office.

Although you do not own your medical record, you have reasonable access to see and copy the record. You should first contact the health care provider who created the record directly. The request can start by informally asking. The health care provider can ask that you fill in a Request to Access Health Information form and pay a minimum $25.00 processing fee. If your request is denied, you can apply for a court order. The writer or institution will then be required to release a copy to you.

If the medical record identifies another person’s identity, if it involves an investigation of a doctor or health team, or other internal processes, then access may be refused. Partial release may be possible instead. Release may also be refused if the doctor believes it will result in “immediate and grave harm.”

Although you have a right to see and copy your record, it may include medical terminology. There is no legal duty on the part of the writer to use language which you understand. If there are words or statements on your record which you do not understand, ask a doctor for an explanation. A term, code, or abbreviation should be explained to you if you ask for an explanation. This is not medical knowledge, but part of the internal process of the doctor or hospital.

The general rule is that your medical records should be kept private and confidential. There are exceptions to this rule. In Alberta, the Minister of Health may demand to see your record to check the standard of care given to patients in hospitals, or for any other reason they consider to be in the public interest. Your hospital record may be released to the Director of Medical Services for Occupational Health and Safety, if

your record refers to an accident which occurred on the job or as a result of your job. Your record can also be released to the Workers’ Compensation Board, the Alberta Blue Cross Plan or other insurance authorities to determine who handles paying your hospital bill. Finally, your records can be given, without your consent, to a hospital you have been transferred to, persons involved in medical research and training, to another medical examiner, and the College of Physicians and Surgeons of Alberta.