{"id":2328,"date":"2024-05-23T15:34:00","date_gmt":"2024-05-23T15:34:00","guid":{"rendered":"https:\/\/medlegal.ca\/?p=2328"},"modified":"2024-08-05T21:03:13","modified_gmt":"2024-08-05T21:03:13","slug":"medical-records-access","status":"publish","type":"post","link":"https:\/\/medlegal.ca\/en\/medical-records-access\/","title":{"rendered":"Who Can Access a Patient\u2019s Medical Records?"},"content":{"rendered":"\t\t
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There are times when we want to keep information confidential. This is particularly true of medical records, which many people prefer to keep secret.<\/span><\/p>

In Canada, as elsewhere, access to patient medical records is highly regulated. Medical records are considered confidential and are therefore protected by law. When documents contain sensitive information, not just anyone can access them.<\/span><\/p>

MedL\u00e9gal’s healthcare lawyers explain what the law says about the right to consult a patient’s medical records.<\/span><\/p>

What is a medical record?<\/span><\/h2>

A medical record is set of documents that contains important information concerning a patient’s health.<\/span><\/p>

Medical records are an important communication tool that enables doctors to keep track of their patients. Your medical file includes details like your medical history, test results, diagnoses, treatments and care received.<\/span><\/p>

It also includes personal, identifying information (name, gender, age, date of birth, etc.).<\/span><\/p>

Medical records are maintained by healthcare professionals so they can monitor a patient’s health and make decisions about future care.<\/span><\/p>

Access to medical records: a confidential file<\/span><\/h2>

As a general rule, a patient’s medical records are confidential, and only the patient can access them. All other people need the patent\u2019s authorization before accessing their medical records.<\/span><\/p>

Section 19 of the Act respecting health services and social services<\/span><\/a> states: “The record of a user is confidential and no person may have access to it except with the consent of the user or the person qualified to give consent on his behalf. Information contained in a user\u2019s record may, however, be communicated without the user\u2019s consent.”<\/span><\/p>

Only healthcare professionals involved in a patient’s treatment have access to their medical records. However, if necessary, a parent, guardian or curator may authorize consultation of a patient’s medical records without their authorization.<\/span><\/p>

The law stipulates that patients age 14 and above are entitled to access their own medical records, as this coincides with the right to individual informed consent to treatment. Accordingly, all patients aged 14 and over have the right to access their medical records, as a matter of <\/span>human rights<\/span>.<\/span><\/p>

In addition, only the patient can authorize others to consult their file. Consequently, a minor aged 14 or over can refuse their parents access to their medical file.<\/span><\/p>

How to access your medical records<\/span><\/h2>

To access your medical records, you must send a written request to the person in charge of protecting personal information at the health establishment or clinic where the services were provided. You can obtain this person’s contact information on site or by contacting the <\/span>Commission d’acc\u00e8s \u00e0 l’information du Qu\u00e9bec<\/span><\/i>.\u00a0<\/span><\/p>

When a person makes a request on their own behalf, they must do so in writing and provide proof of their identity. If another person wishes to make the request, they must explain their motives and provide solid proof of their relationship with the patient.\u00a0<\/span><\/p>

Accessing medical records held in a public healthcare institution<\/span><\/h3>

A request to consult medical records held in a public healthcare institution must be submitted in writing, signed by the applicant and addressed to the establishment’s Privacy Officer. Relevant contact information can be obtained from the establishment’s archives or from the <\/span>Commission d’acc\u00e8s \u00e0 l’information<\/span><\/i>.<\/span><\/p>

The establishment must respond to the request for access within 20 days of receiving it.<\/span><\/p>

If the request is accepted, the individual may consult their file free of charge. Fees may apply to transcribe, transmit or copy the file in whole or in part.<\/span><\/p>

Accessing medical records held in a private healthcare institution<\/span><\/h3>

The application process is identical to that for public institution, however private clinics are allowed 30 days from the date of the request to respond.<\/span><\/p>

Online services<\/span><\/h3>

Qu\u00e9bec Health Booklet<\/span><\/h4>

The <\/span>Qu\u00e9bec Health Booklet<\/span><\/a> is an online service that gives individuals access to a variety of personal medical data, such as their medication list, test results, medical examination reports, list of medical services received and information about who has accessed your file. You must register to access this data.<\/span><\/p>

Qu\u00e9bec Health Record (QHR)<\/span><\/h4>

The <\/span>Qu\u00e9bec Health Record (QHR)<\/span><\/a> is a secure communication platform where authorized professionals can share healthcare information with each other. Information will be automatically shared between any facilities where you receive care, so you don’t need to register. Healthcare professionals can access this information, but patients cannot consult the QHR directly.<\/span><\/p>

What do to do if your request for access is refused<\/span><\/h2>

Requests are rarely refused. Refusals are usually cases where when consulting a person\u2019s medical records could cause serious harm to the person concerned or to others.<\/span><\/p>

If your request is refused, the person responsible must provide you with written reasons for the decision and inform you of the steps you can take before the <\/span>Commission d’acc\u00e8s \u00e0 l’information<\/span><\/i>.\u00a0 They must also help you understand the refusal, if necessary. You may appeal to the Superior Court of Qu\u00e9bec, the Court of Qu\u00e9bec or the <\/span>Tribunal administratif du Qu\u00e9bec<\/span><\/i>.<\/span><\/p>

Who can access my medical records?<\/span><\/h2>

Apart from their own person, only a patient can decide to allow another person (e.g. spouse, legal representative or lawyer) to view their medical records. The patient must provide written authorization allowing this person access to all or part of the medical file.<\/span><\/p>

If a patient wants to grant others access to their medical records for study, teaching or research purposes, they must give their permission in writing, and access is valid only for the duration of the project.<\/span><\/p>

Note also that government agencies, such as health insurers and health care review boards, may also have access to medical records by law, but only for administrative and compliance purposes.<\/span><\/p>

Specific cases where a patient\u2019s medical records can be accessed without their consent<\/span><\/h3>

While the law deems medical records confidential, it also provides for certain exceptions where a patient\u2019s medical records can be accessed without their consent.<\/span><\/p>

Patients under 14 years of age<\/span><\/h4>

Children under 14 years of age cannot consult their own medical records. Only their parents or legal guardians have the right to access their files, and they retain that right until they reach 18 years of age, in most circumstances.<\/span><\/p>

Keep in mind that there are certain situations in which parents and guardians can be refused access to medical information. If you are refused access to a child\u2019s medical records, <\/span>you may appeal the decision<\/span><\/a>.<\/span><\/p>

Incapacitated adults<\/span><\/h4>

A court may declare an adult incapacitated if they are unable to take care of themselves or their property. From then on, a representative can make decisions about their care on their behalf. The representative may be a <\/span>tutor<\/span><\/a>, curator or mandatary.<\/span><\/p>

Note: When a patient cannot make decisions for themselves but has not been declared incapacitated, their spouse or loved one can act as their representative.<\/span><\/p>

A patient\u2019s representative is allowed to access their medical records, but only the information needed to make decisions about their care.<\/span><\/p>

Heirs and family of a deceased patient<\/span><\/h4>

When a patient dies, their heirs and family can access their medical records under certain conditions, for example, if they are suing for <\/span>medical malpractice<\/span>. In this case, they may only have access to limited information.<\/span><\/p>

Heirs must:<\/span><\/p>