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Answer:

Discussion:

20 Medico-legal questions

Question 17: Ownership of medical records

Your patient attended your private office for a health exam for insurance reasons. You hadtreated the patient for depression in the past. The patient was upset because thisinformation was in his medical record and it might affect his eligibility for, or the cost of, life

insurance. He demanded his entire medical record so that he could take it away. Whatshould you do? Choose the best answer:

A)Provide the actual record because it is owned by the patient but kept withthe physician

B)Refuse to give the original because the medical record is owned by the

physician, but offer a copy

C)Provide a copy because the medical record is owned by the provincial payeranyway

D) Provide the original medical record to comply with privacy legislation

E)Refuse because the medical record is not available for viewing by patients

with psychiatric diagnoses in most cases

The answer to this question is: B

Access to medical records

In 1992, the Supreme Court of Canada held:

The physical medical records are the property of the physician.

A patient is entitled, upon request, to examine and receive a copy of thecomplete medical records compiled by the physician in administering advice ortreatment to the patient, including records prepared by other doctors that the

physician may have received.The patient is not entitled to examine or receive copies of any information ormaterial received or compiled by the doctor outside of the doctor-patient

relationship.A patient's general right of access to medical records is not absolute. Physicians

may exercise discretion not to disclose any information they reasonably believeis likely to cause a substantial adverse effect on the physical, mental oremotional health of the patient or harm to a third party. The Court stated thatpatients should have access to the medical records in all but a small number of

circumstances.A patient should have access to the medical record in the ordinary courseunless there are compelling reasons for non-disclosure. The onus is on the

physician to justify a denial of access to the information or records.

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Requests to fraudulently alter the medical record or not to enter important medicalinformation into it should be refused. Either of these could lead to a finding of

professional misconduct or civil liability.

English

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