Professional Secrecy

The Medical Record

Under review

Clinical Case  
Ms. Chantal P. wants to see her own medical record and that of her 12-year-old daughter.
What do you do?

If one accepts the premise that  a person’s state of health is  an integral part of her private life, then the medical record must be considered a confidential document. Section 19 of the Act respecting health services and social services (LSSSS) is clear in this regard:

“The record of a user is confidential and no person may have access to it except with the consent of the user or the person qualified to give consent on his behalf, on the order of a court or a coroner . . .”

The Regulation respecting records, places of practice and the cessation of practice by a physician (sec. 11), adopted by the Collège des médecins du Québec pursuant to the Professional Code (R.S.Q., c. C-26, sec. 91) and the Medical Act also specifies that:

“The physician shall ensure the confidentiality of medical records and restrict access to authorized individuals only.”

Indeed, this Regulation specifies, for all  physicians, the conditions for creating, keeping, holding, maintaining, preserving, using, managing, administering, transferring or handing over medical records.

The rules on the writing and keeping of records vary, depending on whether the physician practices in a consulting room and a CLSC, or in a hospital centre. However, only information relevant to the purpose of the medical record must be part of it. On occasion, it may contain information concerning third parties. This is why certain rules have been established to maintain the confidentiality of the information.