What are medical records?
The clinical notes made by a doctor or hospital staff concerning a patient are the basic content of a patient’s medical records. However, a patient’s complete medical record may also contain: x-rays, test results, reports, and correspondence to and from other doctors and treating specialists.
What information should be in medical records?
Medical records should contain all of a patient’s important medical history.
The doctor or hospital staff should also record details of each consultation, including medications prescribed, procedures carried out, tests ordered and their results.
How confidential are my medical records?
Medical records are confidential.
Information from the records should not be given to third parties (such as insurers, pathologists or other medical practitioners) without your written permission. In a hospital setting, the multidisciplinary nature of care generally requires that your records are readily available to all healthcare professionals involved in your care.
If your records are required at court, a subpoena must be issued before they are released, otherwise than with your consent.
Who owns the medical records?
Medical records are the property of the doctor, practice or hospital but the patient has a right to the information. This is supported by state and federal legislation.
In New South Wales, access to records held by doctors in private practise is governed by the Health Records and Information Privacy Act 2002 and records held by public health institutions such as hospitals is governed by the Government Information (Public Access) Act 2009.
Why don’t I own my medical records?
The records are the notes the doctor or hospital staff makes to assist with treatment. They are made by the doctor or healthcare professionals and are the property of the doctor or hospital. X-rays may be an exception to this and are generally considered the property of the patient, where they have duly paid for the examination.
What happens when a doctor or hospital receives my request for medical records?
The doctor or hospital is required to respond to the request within a reasonable time. A doctor in private practise must respond to a request within 45 days, otherwise you can lodge an official complaint with the Privacy Commissioner. A NSW hospital must generally decide whether or not to provide access to documents within 20 working days of receiving an application. A written reason must be given to refuse access. If no response is forthcoming within the provided timeframe, the doctor or hospital is deemed to have declined access.
The request for access to medical records is often best handled by a solicitor as the law is complex.
Does it cost any money?
Most doctors or hospitals will charge a fee for handling and copying records but this should reflect only the administrative costs involved. A formal application for access to your hospital records will usually incur a $30 application fee.
When might my application for access be refused?
If the doctor or healthcare professional believes releasing the records might harm the patient, due to very confidential or distressing information, access may be denied. This decision can be challenged legally.
The patient can request the damaging records be released to another doctor of their choice.
What happens when a practice changes hands?
The doctor disposing of the practice should make reasonable efforts to ensure records are maintained by giving them to the patient or another doctor identified by the patient.
What if my doctor dies?
If your doctor dies, approach the estate and ask for the records to be sent to another doctor.
How long is a doctor required to keep my records?
Records must be kept for at least:
- seven years for adults
- up to twenty‑five years for children.
How can we help?
Catherine Henry Lawyers can assist you with expert advice and legal support on your rights and options. Our team is highly respected in the health and medical litigation arena, with specialist health and medical law knowledge accumulated over twenty years. We have successfully pursued hundreds of claims against health care providers. Contact us today for further information on 02 4929 3995 or firstname.lastname@example.org.