Kokua Line
Kokua Line
Access to medical records
depends on provider’s OKQuestion: After a visit with my doctor at a Straub clinic, I was handed my medical file and told to return it to the nurses' station and schedule a follow-up appointment. No one was at the counter, so I decided to sit down and review my file. Partway through, I found an interesting notation that my doctor suspected I was using alcohol excessively. Just then a nurse walked up and told me that I was not allowed to look into my file and took it from me. Since this is my medical record, do I have the right to review it? If my file contains information that is untrue, can I demand that it be removed from my file?
Answer: You generally have a right to review your records or to request a copy, unless you are a psychiatric patient, but original medical records are the property of the hospital/health care provider. You cannot have anything removed from your record, but you can have it amended.
At Straub Clinic & Hospital, the procedure for review or for a copy requires you to submit a written application, said spokeswoman Claire Tong. A patient can also schedule an appointment to review his/her records with the physician, she said.
Vanessa Duplechain, Straub's director of medical records, explained that in most instances the health care provider who originated the medical record owns the record.
"It's the information contained in the medical records that belongs to the patient," she said.
By law a patient has the right to access his or her medical records, but only based on approval by the health care provider. In other words, a physician/health care provider has to right to deny access, Duplechain said.
The reason, she said, is that "the law understands, particularly for mental health patients, that sometimes reviewing their records could be more detrimental to them."
The law, however, also says that if access is denied, the patient has a right to apply for an appeal with the health care provider. Although the denial may be overturned, if it is upheld, "then that's the final say," Duplechain said.
As for changing or removing anything from your records, you "can't remove anything," she said.
A patient can ask that information be added to the record if he feels what is in there "is not representative of what he communicated to the physician," she said.
Conversely, "a physician has a right to say, 'No, that's not what you told me, that's not relevant or whatever to the continuity of your care,'" Duplechain said.
In that case, the information the patient wants added, as well as the physician's response, becomes part of the medical record.
If you change doctors or hospitals, a copy of your record will be given to the new health-care provider, Duplechain said. However, the original copy remains with the originating provider.
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