Can a client read their medical record?
Yes, a client may ask to review their records. The preference is for the client to receive a copy of their record, but if they are insistent, they may read the chart under supervision. The manager, physician or nurse must review the records before the client reviews them, to ensure that no inappropriate information is disclosed such as information about other individuals or information that could be harmful. All requests of this nature should be directed to your Health Records Department for advice, and staff should document in the client’s record the date and type of information reviewed. A clinical staff member must be present during the review to ensure the integrity of the chart (and possibly explain elements).
Can a client have copies of their reports or entire medical record?
Yes, a client may request a copy of their record. You may provide the client directly with a copy of a document if you completed it with the client present (e.g. client assessment, care plan). You may also give the client a copy of a single lab or radiology report if they request. If they are requesting a copy of their entire record or records narrative in nature (e.g. progress notes, transcribed reports, case notes), please direct the request to your Health Records Department. Staff should document in the client’s record the date and type of information requested and released. If you are unsure how to address a client’s request, please contact your Health Records Department for advice.
Can a client request changes be made to the documentation in their medical record?
Yes, clients have the right to request corrections, or to make additions, to their personal information. The original record cannot be changed, except for demographic (factual) errors (e.g. incorrect date of birth, address, misspelled name). If the clinician who made the documentation in question agrees to do so, s/he may add additional information to the record as a separate note. The client may also wish to submit a document setting out their addition to the record. Clients are encouraged to be brief in their submissions. All requests for corrections must be in writing and referred to your Health Records Department.
When are client records destroyed?
The information in the records belongs to the client but the records belong to VCH. Since 1996 BC Health Authorities have been under direction from the Ministry of Health to retain health records indefinitely. For this reason VCH cannot comply with requests by clients to destroy their records.
* “Client” means all people receiving services from VCH and includes patients and residents.
Questions?
If you have any questions, please contact the Information Privacy Office at 604-875-5568 or email privacy@vch.ca.
To see a PDF of this memo please click here.