20 Medico-legal questions Test your knowledge

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20 Medico-legal questions

Question 17: Ownership of medical records

Your patient attended your private office for a health exam for insurance reasons. You had treated the patient for depression in the past. The patient was upset because this information was in his medical record and it might affect his eligibility for, or the cost of, life insurance. He demanded his entire medical record so that he could take it away. What should you do? Choose the best answer: A) B) C) D) E) Provide the actual record because it is owned by the patient but kept with the physician Refuse to give the original because the medical record is owned by the physician, but offer a copy Provide a copy because the medical record is owned by the provincial payer anyway Provide the original medical record to comply with privacy legislation Refuse because the medical record is not available for viewing by patients with psychiatric diagnoses in most cases

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Answer:
The answer to this question is: B

Discussion:
Access to medical records In 1992, the Supreme Court of Canada held: The physical medical records are the property of the physician. A patient is entitled, upon request, to examine and receive a copy of the complete medical records compiled by the physician in administering advice or treatment to the patient, including records prepared by other doctors that the physician may have received. The patient is not entitled to examine or receive copies of any information or material received or compiled by the doctor outside of the doctor-patient relationship. A patient's general right of access to medical records is not absolute. Physicians may exercise discretion not to disclose any information they reasonably believe is likely to cause a substantial adverse effect on the physical, mental or emotional health of the patient or harm to a third party. The Court stated that patients should have access to the medical records in all but a small number of circumstances. A patient should have access to the medical record in the ordinary course unless there are compelling reasons for non-disclosure. The onus is on the physician to justify a denial of access to the information or records.

https://education.cmpa-acpm.ca/20questions/questions/question17-e.html

18/02/2012

20 Medico-legal questions Test your knowledge

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Requests to fraudulently alter the medical record or not to enter important medical information into it should be refused. Either of these could lead to a finding of professional misconduct or civil liability.

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https://education.cmpa-acpm.ca/20questions/questions/question17-e.html

18/02/2012