Medical Records

Medical Records

When a patient receives medical treatment or other health care, there is normally a legal and ethical obligation on the health-care provider (as well as the health-care facility, such as a hospital) to keep a detailed written record of the patient's treatment. For example, a hospital record will contain things such as nurses' notes, physicians' notes, a medication chart and the results of any diagnostic and other tests (such as X-rays). Sometimes patients may wish to have access to their own medical record. Do they have a legal right to do so?

In most provinces and territories the legislation which governs the administration of hospitals specifically gives patients a legal right of access to their own hospital records, although the exact procedure for exercising this right tends to vary across Canada. In the case of health care outside of hospital (eg, treatment given in a general practitioner's office), until 1992 it was not entirely clear if patients had a legal right to see their own medical record. However, in that year the Supreme Court of Canada issued a landmark decision which affirmed that patients do indeed have this right. According to the Supreme Court, the doctor (or other health-care provider) is the owner of the actual written record, but the patient has a right of access to the information contained in it. That right stems from the "fiduciary" nature of the relationship between doctor and patient; the relationship is based on trust, and imposes on the doctor obligations of utmost good faith and loyalty towards the patient, and a duty to act in the best interests of the patient. Thus, patients have a right to see (and, if they wish, copy) their own medical record.

The Supreme Court acknowledged that this is not an absolute right, and that there are exceptions to it. In very rare cases it may be appropriate to deny a patient the right of access to his or her own medical record. This will occur, however, only in very exceptional circumstances.