Getting Your Medical Records (No. 421)

From Clicklaw Wikibooks

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.

Understand your legal rights

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 governing 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. The BC Medical Association 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 and their website is cpsbc.ca.

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 oipc.bc.ca.

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.

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.

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 even if you ask them to.

Get help

With more information

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

Toll-free: 1-800-461-3008
Web: cpsbc.ca

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.

Toll-free: 1-800-663-7867
Web: oipc.bc.ca


[updated June 2018]

The above was last reviewed for legal accuracy by Michelle Stimac, College of Physicians and Surgeons of BC.



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