Your patients want to see their
medical records, but not everything in those files is
fit for their eyes. How do you know where to draw the
line? "Each College has its recommendations to practitioners
with regards to patient access to their records," says
Dr Robert Rivington, senior medical officer at the Canadian
Medical Protective Association (CMPA). Here are 10 things
you need to know before you pull those files.
1 Do patients have a right to
the original records? No. By law, the patient has
the right to have their records out of respect for their
autonomy. But this right is limited to a copy of the
records — not the original — since those are
legally yours.
2 Can they see everything?
"No," says Dr Rivington. "They have access to the vast
majority of the information in their files, but there
are exceptions." Those exceptions that might harm the
patient physically or mentally — such as sensitive
psychiatric records — or bring harm to someone
else can be withheld. However, if they ask, you'll have
to justify why you felt the patient shouldn't see some
parts of their records, adds Dr Rivington.
3 If you made a non-medical
comment, should you censor it? It's best not to
write it in the first place, says Dr Rivington. The
Royal College of Physicians and Surgeons of Canada cites
a case where a radiologist had trouble getting a patient's
co-operation with a test because he was "a bit of a
wimp." Lucky for the radiologist, it's ok to expunge
inflammatory statements that are medically irrelevant
from the copy you give to patients. But Dr Rivington
emphasizes: "Physicians should avoid inappropriate comments,
and be factual and professional."
4 What about reports from other
carers or providers? "Basically, any information
in the health records that arises from care provided
through the provincially-funded system is accessible,"
says Dr Rivington. For other reports, like the ones
from insurance companies for instance, different provinces
have different rules. When in doubt, contact the CMPA,
Dr Rivington recommends.
5 Can you charge a fee for copying
records? Absolutely, says Dr Rivington. "It costs
the physicians for use of their secretary's time and
photocopier, so it is their right to charge for this
service." In fact, each provincial College has a statement
about charging and many even propose a fee for the service,
he adds. (For more on how to facilitate charging fees
in your practice, see "Get
paid for providing uninsured services".)
6 Are patients allowed to make
changes to their records? "They're permitted to
propose corrections or modifications to the information
in their records," Dr Rivington says. But physicians
are encouraged not to alter the original record. Instead,
Dr Rivington suggests the doctor add a note that "on
X date, the patient corrected the piece of information
Y in the record."
7 Should the patient put their
request in writing? "Most physicians should request
something in writing," Dr Rivington recommends.
8 Can anyone else request records
on behalf of a patient? "If the patient is incapable
of speaking for themselves, then whoever has the power
of attorney for personal care can request the records
on their behalf," says Dr Rivington. If it's a child,
then the parents have access. But there's a caveat,
he warns. "If there's a matrimonial dispute, physicians
must be cautious about allowing a non-custodial parent
access to the records." You could seek legal advice
to determine who gets to see what, adds Dr Rivington.
9 What if the patient wants
the records sent to a third party? There's nothing
to stop docs from complying with that wish. But sometimes
there's very sensitive information in the files that
the patient might not even know is there. For example,
if there's mention of childhood sexual abuse, and the
patient asks you to send the records to their employer
— this puts you in a delicate position. "We suggest
that the physician have the patient come in and show
them the information in the file, then decide what to
do," says Dr Rivington.
In some cases, it's not even necessary
to send all the medical records, according to Dr Rivington.
"If the patient has a condition and they're travelling
to another country, then a simple letter might help
introduce them to a doctor in that country, rather than
the entire file."
10 Should you make access to
the records easier for your patients? "I'm not sure
it's in the best interest of patients to always have
a copy of their records," he says. "The records are
not always in plain English. Most physicians are uncomfortable
providing the health information directly to the patients
and would prefer to give it to another physician."
Keep in mind, the whole point of
giving patients access to their records is to help them
make informed decisions about their health. There's
nothing to stop you from having an informal session
with them, going over the records and explaining the
medical terms, says Dr Rivington.
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