The Medical Record

Access to the Medical Record

Under review

Even if the medical record is a confidential document, according to all laws, the patient in Québec has the right to read the content of her file and obtain a copy of itCOLLÈGE DES MÉDECINS DU QUÉBEC, L’accès aux renseignements personnels contenus dans le dossier médical constitué par le médecin exerçant en cabinet : guide d’exercice. Montreal, Collège des médecins du Québec, May 2007. However, the physician must always make sure that the original is kept; indeed, the physician is the medical record’s custodian. Pursuant to the provision in the  Professional  Code prescribing that all professionals respect this right (sec. 60.5) the Code of Ethics of Physicians (sec. 94) stipulates that,

“A physician must, promptly and within not more than 20 days of its receipt, respond to any request made by his patient 14 years of age or older to examine or obtain a copy of documents concerning him in any record established in his respect.”

The rules on the age at which one may have access to one’s medical record differ slightly from those concerning consent to treatment. Barring exceptions, it is therefore the person with parental authority, notably the father or mother, who has the right to access the medical record of a minor under 14 years of age. However, a physician must obtain the consent of a minor 14 years of age or older before communicating to the minor’s parent or tutor health information connected with care to which the minor may give his or her consent alone (Code of Ethics of Physicians sec. 94). Persons 14 years of age or over may have independent access to their medical record. In an institution, the person with parental authority may also have access to the record of a minor 14 years of age or over, under certain conditions. In fact, the LSSSS stipulates that an institution must refuse this access if the patient herself does not consent to it and if the institution determines that the communication of the information in the record could cause harm to the patient’s health, even if the harm is not serious (sec. 21).

Ms. Chantal P. is therefore entitled to have access to her record, which does not include information about a third party. If such information were contained in the record, it would have to be removed before answering her request.

Ms. Chantal P., the person with parental authority, may also have access to the record of her minor daughter, who is under 14 years of age, provided there are no other restrictions.