The patient has the right to access the medical documentation regarding his he alth condition and the he alth services provided to him. The data contained in the medical documentation is legally protected and belongs to the category of the so-called sensitive data.
It is worth knowing that doctors, nurses and midwives are authorized to obtain and process data resulting from the patient's treatment process, calledmedical records . Entries in the documentation are made immediately after the he alth service is provided, legibly, in chronological order and marked with the data identifying the person making the entry. The entry made in the documentation cannot be removed from it, and if it was made incorrectly, it should be deleted, provided with the date of deletion, a short description of the reasons for deletion and marked with the data identifying the person making the deletion.
Medical records should include:
1. designation of the patient, allowing for the identification of the patient:
- surname and given name (s),
- date of birth,
- gender,
- home address,
- PESEL number, if assigned, in the case of a newborn - mother's PESEL number, and in the case of people who do not have a PESEL number - type and number of the document confirming their identity,
2. if the patient is a minor, completely incapacitated or incapable of expressing consent - the surname and first name (s) of the legal representative and the address of his / her place of residence; designation of the entity providing he alth services with an indication of the organizational unit in which the he alth services were provided;
3. description of the patient's he alth condition or he alth services provided;
4. date of preparation.
The entity providing he alth services is therefore obliged to provide the patient with access to medical records or their statutory representative appointed for this purpose (if the information about the he alth condition concerns, for example, minor children), or a person authorized by the patient (e.g. a spouse, baby). After the patient's death, the person authorized to do so by the patient during his lifetime has the right to access the medical documentation. If there was no such authorization, information on the state of he alth and causesdeath of the patient, is made available to the closest person of the deceased.
Medical records are shared:
1) for inspection, including databases in the field of he alth protection, at the premises of the entity providing he alth services;
2) by making its excerpts, excerpts or copies;
3) by issuing the original with a receipt and subject to return after use, if an authorized body or entity requests the originals of this documentation.
Fees for providing medical documentation
It is worth knowing that the provision of medical documentation by the entity providing he alth services may be subject to a fee. Fees are not collected when medical documentation is made available in connection with proceedings before the provincial commission for adjudication on medical events. The fee for providing medical documentation is always set by the entity that provides he alth services.
Maximum fee for the provision of documentation
1) one page of an extract or excerpt from medical records - may not exceed 0.002 of the average salary in the previous quarter, determined on the basis of art. 20 point 2 of the Act of December 17, 1998 on pensions from the Social Insurance Fund;
2) one page of a copy of medical records - cannot exceed 0.0002 of the average salary;
3) preparing an excerpt, excerpt or copy of medical documentation on an electronic data carrier, if the entity performing medical activities keeps electronic medical documentation - it cannot exceed 0.002 of the average salary.
Legal basis:
Act of November 6, 2008 on the rights of the patient and the Patient's Rights Ombudsman (Journal of Laws of 2012, item 159 as amended)
Act on the protection of personal data (Journal of Laws of 2002 No. 101 item 926 as amended)