The patient has the right to access medical records. So what is worth knowing when applying for it? Rafał Janiszewski, the owner of the Advisory Office providing services in the field of he althcare organization for medical entities and patients' rights, tells about the procedure for obtaining medical documentation.
Anna Tłustochowicz: A problem that patients often complain about is difficulties in accessing medical records.
Rafał Janiszewski:It's true. Patients have a lot of problems with access to medical records, and these problems result, firstly, from organizational difficulties of a given hospital or clinic, and secondly - from the ignorance of the patients themselves.
Ignorance of patient's rights?
Yes, of course. As a rule, medical documentation is created and stored by a medical entity: hospital, clinic and any other place where patients are provided with he alth services.The he althcare provider is required to have this documentation at his / her place at all times , and under the Patient Rights Act - the patient has the right to access it. Now let's explain, what do we mean by access?
Access means that the medical entity must provide it with documentation upon patient's request.
How?
It is the patient who has to choose. There are various forms of making medical records available. The first is insight.
Do we then have the right to photograph the documentation, e.g. with a smartphone?
Yes. We can take photos. Currently,medical records are also available in electronic formand then we have access to databases that are in the system.
What is the next form of access?
Possibility to receivean extract, excerpt, copy or printout . The extract is a brief infraction of what is in our medical records. The copy means that our documentation has been rewritten.
For what purpose?
It is important because such a copy has the value of a certified original. There is a signature, there is a stamp. Same as an excerpt from a notarial deed. As a rule,patient cannot receive, neither canborrow the original of your medical documentation.The original is always in the medical entity. So, if we want to receive something that will have the value of a certified original, this is a copy.
And the copy is simply a photocopy?
These are copies made on a photocopier, and in the case of electronic documentation - a digital copy of the data. And there is also a printout, which is just a collection of information and as such is not a medical record, because it does not need to be signed.
Unlike the write-off.
Yes. Therefore, we have such forms of making medical records available to the patient. And what is extremely important: thatthis happens only on his request!The request can be made orally, it can be made over the phone, or it can be made in writing. At the same time, it is important to know that the hospital cannot require the patient to submit a special form or fill out any specific application. Not!
The law clearly states that the patient can request his documentation in any way. How convenient for him. However, what else is important? That the documentation is most often made available to the patient in person or to the person he or she has authorized.
Can't call and request documentation by e-mail?
No, becausethe hospital has to check if it provides documentation to an authorized person.And by phone how do we know who is calling? There is no possibility of verification. What else is the mail. The hospital may provide us with the documentation via e-mail, provided that we have previously submitted a declaration at this hospital and indicated this specific e-mail address to which we would like to share this documentation with us.
And if the patient, while in hospital, made such a declaration, then he does not have to bother and go for his documentation?
That's right.
And how quickly documentation must be made available to the patient
The act specifies that it should happen "without undue delay".
What does this mean?
Well, that doesn't mean "immediately", butas soon as possible . Patients often get irritated that they do not receive their documentation right away. Only that you have to be aware that this is not always possible, because the medical documentation is archived in the medical entity. It's in the archives, so you have to go there and find it. On the other hand, the documentation in electronic form is stored on servers.
So this should be a moment - a moment!
Not necessarily, because servers have multiple levels of security that can be accessed by specific people!
Sharing the documentation really cannot always be done right away. Which does not change the fact that it must take place "without undue delay". Pretty fast, that is.
In practice, most often we submit a request to the hospital, it accepts it from us and contacts us after our documentation has been prepared for us. It is worth saying thatwe should clearly state in our request, in what form we want our documentation to be made available to us,but also what specifically we want. The whole thing? Is it just a specific passage? If a specialist has been seeing us in the clinic for several years, or in a hospital we have been hospitalized several times and the stays lasted for weeks.
This documentation will be bloated volumes!
Exactly! We should remember that when we are in hospital, everything that happens to us is recorded every day: tests that are performed and their results, medications taken, procedures performed.Documentation can be cavernous , so we must clearly define whether we want to receive everything that is in it, or, for example, we only need information from a specific day and a specific activity, e.g. we request a surgical procedure protocol or order cards with drugs, or, for example, only the results of tests that have been done to us.
This is also important because you have to pay for medical records, right?
Sharing ispaid, but the first access is free.Each subsequent time is paid, and the fee is variable. Depending on the form of sharing: whether it is to be a copy or a printout, and so on. When it comes to, for example, one copy, these are not large amounts, which are specifically determined by specific hospitals, but if we already have documentation of 400-500 pages? You really have to think about whether you really want to make a copy of everything, or do you really want to get documentation in paper form?
Maybe it would be wiser to request an electronic form and print out what we need.
Sometimes a patient asks for documentation when there is a medical error and wants to sue the hospital. We are then afraid that the hospital may refuse to provide us with our documents.
The hospital cannot fail to deliver our medical records to us!You cannot refuse it.And if we encounter any difficulties in accessing our documentation, such a situation should beimmediately report to the Patient Ombudsman. I can say thatreally the MPC in this area works very effectively and quickly.On his website you can find the recommendations that the Ombudsman issued, which concern the sharing of medical records. There, a clear signal is sent to medical institutions that they must not create any barriers in this regard! No restrictions on access to medical records for authorized persons!
Expert
Rafał Janiszewski, owner of the Advisory Office providing services in the field of he althcare organization to he althcare entities
Speaker, organizer of many trainings and conferences on he alth protection and patient rights. In the years 1998-1999 an employee of the Office of the Government Plenipotentiary for the Implementation of the General He alth Insurance. Author of over 20 books on he althcare organization and he alth care financing standards. In 2005-2007, he was an expert of the Presidium of the Parliamentary He alth Committee, as an advisor on he alth services. Co-author of the general study as part of the Pharmaceutical Pricing and Reimbursement project for the European He alth Commission.
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