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.
Non-identifying information may be used in any way. For example, if a hospital is collecting the number of patients diagnosed with a type of cancer, and you have this cancer, then your diagnosis will be added as a number. Your name will not be used. If in-depth information is going to be used, involving identifying information, the researcher would need to get permission from an ethics committee. The ethics committee may say that consent is not needed. They will make their decision on how difficult it is to get your consent.
If a hospital or doctor wishes to give another person or institution access to your record, they must first get your written consent. If you refuse consent, the person or institution wishing to read your record can apply for a court order to have the record released. If the hospital refuses to allow someone access to your record but you want that person to have access, you can apply to court yourself for an order requiring the hospital to release the record.
If the hospital or doctor releases your medical record to someone who is not authorized to see it, the person releasing the record is guilty of an offence. They may be fined, in default of payment, or imprisoned. You should contact the Information and Privacy Commissioner who can investigate the complaint. Call them at 403-297-2728.
Hospitals and doctors must keep records of all patients for at least 10 years from the date of the last record entry. Some hospitals keep their records for a much longer time than this. Hospitals are also required to keep charts of babies born in the hospital for at least 10 years after they turn 18. A pharmacist records of prescriptions may begin to be destroyed after 3 and a half years.
In the hospital, doctors must read the whole chart. Doctors also must properly record all medications that are given. If a doctor fails in either of these responsibilities, and you suffer damages as a result of this failure, the doctor may be guilty of malpractice.
In summary, a medical record includes documents that have medical information about your health care. Your medical report belongs to the person or institution that wrote it. Even though you cannot take your record without the writer’s permission, you do have a right to access to your record and can enforce this right through a court order. Some other organizations, including the government, also have a right to access your file. If you wish someone to have access to your file, you may give consent in writing. In general, the record should be kept private and confidential.
If you have questions or would like assistance in requesting access to medical records, you are encouraged to contact Health Information Access Services toll-free by dialing 310-000 then 780-422-5111. For access to health information online please visit www.albertanetcare.ca and create an account. For detailed information on access and disclosure of your medical information, visit https://www.albertahealthservices.ca/about/Page13433.aspx.