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The topics in the Dial-A-Law series provide general information on a wide variety of legal issues in the Province of Alberta. This service is provided by Calgary Legal Guidance funded in part by the Alberta Law Foundation.
This topic will deal with the law concerning access to or ownership of medical records. For the purposes of this discussion, a medical record refers to a chart which aids doctors and other medical staff in treating you. A medical record may be kept on paper but is often eventually transferred to microfilm.
In the doctor’s office, the medical record reminds the doctor of your medical history, consultations, tests run, treatments given and their results. In the hospital, your medical record contains such information 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 in informing the many different people involved in your care of what has happened prior to their involvement.
The physical medical record belongs to the person or institution who originally made it up and maintained it. 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 are entitled to reasonable access to examine and copy the record provided you pay a legitimate fee for the preparation and reproduction of the information. The “record” includes opinions of other doctors which have been sent to your doctor about your health or condition. If your request is refused, you can apply to court for an order directing the writer or institution to release a copy of it to you. The writer or institution, if unwilling to release it to you has to show good reason why it should not be released.
Although you have a right to see and copy your record, it may include medical terminology and 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.
The general rule is that your medical records should be kept private and confidential. There are, however, many exceptions to this rule. In Alberta, the Minister of Hospitals and Medical Care may demand to see your record to check into the standard of care given to patients in hospitals, or, for any other reason considered by the Minister to be in the public interest. Your hospital record may be released to the Director of Medical Services of Alberta, when your record refers to an accident which occurred on the job or as a result of your job. The Director of Medical Services is a doctor who is appointed by the government to investigate occupational injuries or diseases. Your record can also be released to the Workers’ Compensation Board, the Alberta Blue Cross Plan or other insurance authorities to determine who is responsible for paying your hospital bill. Finally, your records can be given, without your consent, to a hospital to which you have been transferred, to the Government of Alberta or the Government of Canada, to persons involved in medical research and training, to a medical examiner and to the College of Physicians and Surgeons of Alberta.
If a hospital or doctor wishes to give another person or institution access to your record they must first obtain 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 wish 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 one releasing the record is guilty of an offence and may be fined, and in default of payment, imprisoned.
By law, hospitals must keep records of all in-patients for seven to ten years. Some hospitals, however, keep their records for a much longer time than this. Hospitals are also required to keep charts of babies born in the hospital for twenty years.
In the hospital, doctors reading the chart have a duty in law to read the whole chart. Doctors also have a duty to record correctly 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 is made up of documents containing medical information regarding your health care. Your medical report belongs to the person or institution that wrote it. Although 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 by court order. Some other organizations, including the government, also have a right to access to your file. If you wish someone to have access to your file, you may give consent in writing. In general, however, the record should be kept private and confidential.