Difference between revisions of "Getting Your Medical Records"

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{{Dial-A-Law Blurb}}
{{REVIEWEDPLS | reviewer = Michelle Stimac, College of Physicians and Surgeons of BC|date= June 2018}} {{Dial-A-Law TOC|expanded = health}}
Under BC law, the information in your medical records belongs to you. Learn your rights relating to your medical records, who has access to them, and how to get them.


{{Dial-A-Law TOC|expanded = health}}
==What you should know==
This script explains who owns medical records and the information in them, how to see your own medical records, and who else can see them.


==Who do medical records belong to?==
===The information in your medical records belongs to you===
Many people think that their medical records are their own property, and that if they want to see them, they just have to ask. That’s only partly true. Your medical records actually belong to the doctor, hospital, or other place that made them, not to you. That’s also true for dental records and nursing home records. But the information in the medical records belongs to you. And normally, you have a right to see that information. The records should include any treatment or procedure that went wrong because courts have said that doctors have a legal duty to give patients that type of information.
Many people think their medical records are their own property, and if they want to see them, they just have to ask. That’s only partly true. Your medical records actually belong to the doctor, hospital, or other place that made them, not to you. That’s also true for dental records and nursing home records.


==Medical records that your doctor keeps==
But the '''information''' in the medical records belongs to you. You have a right to see that information. The records should include any treatment or procedure that went wrong. Courts have said doctors have a legal duty to give patients that type of information.
To see your medical records kept by your doctor, just ask the doctor to see them. Your doctor has a privacy officer—usually the doctor—to deal with the request. Under the BC ''[http://www.bclaws.ca/civix/document/id/complete/statreg/03063_01 Personal Information Protection Act]'', you have a right to see the information. And the doctor will normally show you the records or give you the information in them. You can also ask for a copy of your records, but the doctor may charge you a fee (set by the BC [https://www.doctorsofbc.ca/ Medical Association] in its [https://www.doctorsofbc.ca/sites/default/files/public_uninsured_services_2015apr01.pdf fee guide]) to copy them because medical insurance does not pay for this. You could also ask to take a picture of the records with your phone—this option is quite new so doctors may not have a position on it yet.


Doctors have to keep medical records for at least 16 years from the last entry in the record, or from when the patient reaches the age of majority (19 years old in BC)—whichever comes later.  
===Your medical records held by your doctor===
The regulatory body for doctors in British Columbia, the College of Physicians and Surgeons of BC, requires all doctors to keep and securely store accurate records for every patient, with the date and type of service provided to the patient. [https://www.canlii.org/en/bc/laws/stat/sbc-2003-c-63/latest/sbc-2003-c-63.html Under the ''Personal Information Protection Act''], doctors must make sure the information in your medical records is accurate and to keep it private.


'''Accuracy and privacy of doctor records'''—the College requires all doctors to keep and securely store accurate records for every patient, with the date and type of every service provided to them. And the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/03063_01 Personal Information Protection Act]'' requires doctors to make sure the information in your medical records is accurate and to keep it private. If you think the doctor made a mistake in your medical records, you can ask them to fix it. The doctor has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.
[http://canlii.ca/t/842p Under another law in BC], your doctor must keep your medical records for at least 16 years from the date of the last entry in the record. As well, your doctor must keep any records from when you were a minor (that is, under age 19) until you reach age 35, regardless of when the last entry in the record was made.


Rarely, a doctor may refuse to give you the information in your medical record, thinking that it could cause immediate or grave harm to your safety or to your physical or mental health. If that happens, and you can’t solve the problem with your doctor, contact the [http://www.cpsbc.ca/ College of Physicians and Surgeons of BC]. The College’s Complaints Department may be able to help you. The College phone number is 604.733.7758 in Vancouver and 1.800.461.3008 elsewhere in BC.
====To see the medical records held by your doctor====
To see your medical records kept by your doctor, ask the doctor to see them. Your doctor’s office has a privacy officer — usually the doctor — to deal with the request. [https://www.canlii.org/en/bc/laws/stat/sbc-2003-c-63/latest/sbc-2003-c-63.html Under the ''Personal Information Protection Act''], you have a right to see the information. And the doctor will normally show you the records or give you the information in them.


If you still can’t solve the problem, contact the [http://www.oipc.bc.ca/ Information & Privacy Commissioner for BC]. The Commissioner’s phone number in Victoria is 250.387.5629 and the email is [mailto:info@oipc.bc.ca info@oipc.bc.ca]. Outside of Victoria, call Enquiry BC and ask for the Office of the Information & Privacy Commissioner. To reach Enquiry BC, call 604.660.2421 in the lower mainland and 1.800.663.7867 elsewhere in BC.
====To get a copy of your medical records====
Ask the doctor for a copy of your records. They may charge you a fee to copy them, as the Medical Services Plan does not pay for it. [https://www.doctorsofbc.ca/ Doctors of BC sets approximate fees in its fee guide]. Alternatively, you could ask to take a picture of the records with your phone.


Lastly, you can see a lawyer for legal advice on what to do.  
If you can’t get your medical records from your doctor (for example, if the doctor moved or retired and you can’t find them, or if they refuse to give you the information), you can contact the College of Physicians and Surgeons of BC for help. Their phone number is 1-800-461-3008 or you can [http://www.cpsbc.ca/ visit their website].


==Medical records that hospitals and other public entities keep==
You can also contact the Information & Privacy Commissioner for BC. You can reach the Commissioner by calling Enquiry BC at 1-800-663-7867 or [http://www.oipc.bc.ca/ visiting the Commissioner's website].
To see your hospital records, contact the medical or health records department of the hospital and ask for their information and privacy office or the person in charge of giving out information. If you make a written request, the hospital has 30 days to respond. Usually, you can see your hospital records and get a copy. The ''[http://www.bclaws.ca/civix/document/id/complete/statreg/96165_00 Freedom of Information and Protection of Privacy Act]'' covers records kept by hospitals and other public entities. Check script [[Freedom of Information and Protection of Privacy (Script 235)|235]], called “Freedom of Information and Protection of Privacy” for more on this law.  


'''Accuracy and privacy of hospital records'''—the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/96165_00 Freedom of Information and Protection of Privacy Act]'' requires hospitals to make sure the information in your medical records is accurate and to keep it private. This law also gives you the right to ask the hospital to correct any errors or omissions in your records. The hospital has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.
====Fixing a mistake in your records====
If you think the doctor made a mistake in your medical records, you can ask them to fix it. The doctor has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.


Hospitals have to keep most medical records for at least 10 years (and some for 6 years) under the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/121_97#section14 Hospital Act Regulation]''.  
===Your medical records held by hospitals===
[https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-165/latest/rsbc-1996-c-165.html The ''Freedom of Information and Protection of Privacy Act''] requires hospitals to make sure the information in your medical records is accurate and to keep it private. [https://www.canlii.org/en/bc/laws/regu/bc-reg-121-97/latest/bc-reg-121-97.html#sec14_smooth Under another law in BC], hospitals have to keep most patient records for at least 10 years from discharge. (Less pertinent patient records have shorter periods they must be kept for.)
 
To see your hospital records, contact the medical or health records department of the hospital. Ask for their information and privacy officer or the person in charge of giving out information. You can make a written request. The hospital has 30 days to respond. Usually, you can see your hospital records and get a copy.


If a hospital refuses to let you see your records, it must tell you why. If you disagree with the hospital’s decision, you can ask the Information and Privacy Commissioner for BC to review it.
If a hospital refuses to let you see your records, it must tell you why. If you disagree with the hospital’s decision, you can ask the Information and Privacy Commissioner for BC to review it.


Lastly, you can see a lawyer for legal advice on what to do.  
[https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-165/latest/rsbc-1996-c-165.html Under the ''Freedom of Information and Protection of Privacy Act''], you have the right to ask the hospital to correct any errors or omissions in your records. The hospital has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.
 
===Your medical records are confidential===
Health care providers have a duty of '''confidentiality''' to you. This means they can’t share information about you with others without your permission — except in a few specific situations.
 
One relates to the health care providers who treat you. These providers are said to be in your “circle of care.” They’re allowed to share whatever records are relevant to your care and treatment.


''Are your medical records confidential?''
As well, the law requires health care providers to disclose information about a patient in certain situations. For example:
Yes, medical records are normally confidential. Doctors and hospitals must not give them to anyone else, except in certain cases:  
# Other people who give you medical care, such as specialists, will need your medical records.
# If you’re in a lawsuit about your medical history, your lawyer will need your medical records. Usually, doctors and hospitals will copy your medical records to your lawyer if you ask them to.
# A court can order your medical records be shown to other people and lawyers in a lawsuit.
# If you apply for life or health insurance, the insurance company will often need your medical records before giving you insurance.
# Some types of jobs may require medical information. However, potential employers can get your records only if you agree to let them see the records.


[http://www.bclaws.ca/civix/document/id/complete/statreg/03063_01#section18 Section 18] of the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/03063_01 Personal Information Protection Act]'', which applies to doctors, lists other reasons for giving out personal information—some of them could apply to medical records. [http://www.bclaws.ca/civix/document/id/complete/statreg/03063_01#section33 Section 33] of the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/96165_00 Freedom of Information and Protection of Privacy Act]'', which applies to hospitals, lists other reasons for giving out personal information—some of them could apply to medical records.
* A provider who believes a child is being abused or neglected has a duty to report their concern to a child welfare worker.
* A doctor who has a patient who continues to drive, despite a medical condition that makes it dangerous to do so, must report the patient to the provincial authorities.
* A doctor who believes a patient poses an imminent risk of serious harm to someone has a duty to tell the police.


Doctors also have to release medical information to authorities in certain cases. For example, they must:
As well, health care providers may disclose information about a patient in some other situations, such as:
* report children at risk to the Ministry of Children and Family Development.
* tell the motor vehicle branch when a person's ability to drive may be reduced.
* tell police if someone’s life or safety may be at risk.


And if police have a search warrant, a doctor may have to release information to obey the warrant.
* A court orders that medical records be shown to other parties and lawyers in a lawsuit.
* The police obtain a search warrant to seize a person’s medical records.
* Disclosure is necessary for a person’s medical treatment but they themselves aren’t able to consent (for example, an emergency situation).


==What If you want your medical records destroyed?==
===If someone asks to see your medical records===
The law requires medical records to be kept for the times explained above, so doctors and hospitals cannot destroy your medical records even if you ask them to.  
There are situations in which someone may ask for your permission to see your medical records. For example:


==More information==
* If you apply for life or health insurance, the insurance company may ask to see medical information before giving you insurance.
Check ''[https://www.oipc.bc.ca/guidance-documents/1470 Privacy and Security in the BC Health Care System Today]'', produced by the [https://www.oipc.bc.ca/ Office of the Information & Privacy Commissioner for British Columbia]. It gives an overview of the topic and outlines the expectations of doctors and hospitals.
* An employer may ask to see medical information if you apply for a job that’s safety-sensitive.
* If you make a complaint about a doctor to the College of Physicians and Surgeons of BC, your medical records may be necessary to investigate your concerns.


You’re free to say no to these requests. But there may be consequences. The insurance company can decline your insurance application. The employer can choose not to hire you. You may not be able to proceed with the complaint.


[updated March 2016]
If you want someone to see information in your medical records (for example, you want a family member to help you make health care decisions), talk to your health care provider about letting the person receive your medical records.


===If you want your medical records destroyed===
The law requires medical records to be kept for the times explained above. Doctors and hospitals cannot destroy your medical records during that time even if you ask them to.


----
==Who can help==
----


===With more information===
The '''College of Physicians and Surgeons of BC''' deals with complaints against doctors in BC.
* Call 1-800-461-3008 (toll-free)
* [https://www.cpsbc.ca/ Visit website]
The '''Office of the Information & Privacy Commissioner for BC''' deals with complaints against hospitals and other public bodies such as health authorities. It also reviews decisions by health care providers in private practice, including where and how your medical records are shared.
* Call 1-800-663-7867 (toll-free)
* [https://www.oipc.bc.ca/ Visit website]
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Latest revision as of 00:36, 8 October 2020

This information applies to British Columbia, Canada. Last reviewed for legal accuracy by Michelle Stimac, College of Physicians and Surgeons of BC in June 2018.

Under BC law, the information in your medical records belongs to you. Learn your rights relating to your medical records, who has access to them, and how to get them.

What you should know

The information in your medical records belongs to you

Many people think their medical records are their own property, and if they want to see them, they just have to ask. That’s only partly true. Your medical records actually belong to the doctor, hospital, or other place that made them, not to you. That’s also true for dental records and nursing home records.

But the information in the medical records belongs to you. You have a right to see that information. The records should include any treatment or procedure that went wrong. Courts have said doctors have a legal duty to give patients that type of information.

Your medical records held by your doctor

The regulatory body for doctors in British Columbia, the College of Physicians and Surgeons of BC, requires all doctors to keep and securely store accurate records for every patient, with the date and type of service provided to the patient. Under the Personal Information Protection Act, doctors must make sure the information in your medical records is accurate and to keep it private.

Under another law in BC, your doctor must keep your medical records for at least 16 years from the date of the last entry in the record. As well, your doctor must keep any records from when you were a minor (that is, under age 19) until you reach age 35, regardless of when the last entry in the record was made.

To see the medical records held by your doctor

To see your medical records kept by your doctor, ask the doctor to see them. Your doctor’s office has a privacy officer — usually the doctor — to deal with the request. Under the Personal Information Protection Act, you have a right to see the information. And the doctor will normally show you the records or give you the information in them.

To get a copy of your medical records

Ask the doctor for a copy of your records. They may charge you a fee to copy them, as the Medical Services Plan does not pay for it. Doctors of BC sets approximate fees in its fee guide. Alternatively, you could ask to take a picture of the records with your phone.

If you can’t get your medical records from your doctor (for example, if the doctor moved or retired and you can’t find them, or if they refuse to give you the information), you can contact the College of Physicians and Surgeons of BC for help. Their phone number is 1-800-461-3008 or you can visit their website.

You can also contact the Information & Privacy Commissioner for BC. You can reach the Commissioner by calling Enquiry BC at 1-800-663-7867 or visiting the Commissioner's website.

Fixing a mistake in your records

If you think the doctor made a mistake in your medical records, you can ask them to fix it. The doctor has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.

Your medical records held by hospitals

The Freedom of Information and Protection of Privacy Act requires hospitals to make sure the information in your medical records is accurate and to keep it private. Under another law in BC, hospitals have to keep most patient records for at least 10 years from discharge. (Less pertinent patient records have shorter periods they must be kept for.)

To see your hospital records, contact the medical or health records department of the hospital. Ask for their information and privacy officer or the person in charge of giving out information. You can make a written request. The hospital has 30 days to respond. Usually, you can see your hospital records and get a copy.

If a hospital refuses to let you see your records, it must tell you why. If you disagree with the hospital’s decision, you can ask the Information and Privacy Commissioner for BC to review it.

Under the Freedom of Information and Protection of Privacy Act, you have the right to ask the hospital to correct any errors or omissions in your records. The hospital has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.

Your medical records are confidential

Health care providers have a duty of confidentiality to you. This means they can’t share information about you with others without your permission — except in a few specific situations.

One relates to the health care providers who treat you. These providers are said to be in your “circle of care.” They’re allowed to share whatever records are relevant to your care and treatment.

As well, the law requires health care providers to disclose information about a patient in certain situations. For example:

  • A provider who believes a child is being abused or neglected has a duty to report their concern to a child welfare worker.
  • A doctor who has a patient who continues to drive, despite a medical condition that makes it dangerous to do so, must report the patient to the provincial authorities.
  • A doctor who believes a patient poses an imminent risk of serious harm to someone has a duty to tell the police.

As well, health care providers may disclose information about a patient in some other situations, such as:

  • A court orders that medical records be shown to other parties and lawyers in a lawsuit.
  • The police obtain a search warrant to seize a person’s medical records.
  • Disclosure is necessary for a person’s medical treatment but they themselves aren’t able to consent (for example, an emergency situation).

If someone asks to see your medical records

There are situations in which someone may ask for your permission to see your medical records. For example:

  • If you apply for life or health insurance, the insurance company may ask to see medical information before giving you insurance.
  • An employer may ask to see medical information if you apply for a job that’s safety-sensitive.
  • If you make a complaint about a doctor to the College of Physicians and Surgeons of BC, your medical records may be necessary to investigate your concerns.

You’re free to say no to these requests. But there may be consequences. The insurance company can decline your insurance application. The employer can choose not to hire you. You may not be able to proceed with the complaint.

If you want someone to see information in your medical records (for example, you want a family member to help you make health care decisions), talk to your health care provider about letting the person receive your medical records.

If you want your medical records destroyed

The law requires medical records to be kept for the times explained above. Doctors and hospitals cannot destroy your medical records during that time even if you ask them to.

Who can help

With more information

The College of Physicians and Surgeons of BC deals with complaints against doctors in BC.

The Office of the Information & Privacy Commissioner for BC deals with complaints against hospitals and other public bodies such as health authorities. It also reviews decisions by health care providers in private practice, including where and how your medical records are shared.

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