Your Medical Records: What You Should Know

EMR

For a good part of my childhood, my mom would take me to almost monthly visits to my pediatrician who was treating my rheumatoid arthritis. She also accompanied me for more blood tests and x-rays than I have ever ordered on a child.

Though I’m sure I thanked my mother each time she took me out, I wish I could thank her again for all the concern I must have caused her. She would reassure me so I wouldn’t have to worry.

Curious about the results of all those tests, I requested my records after graduating and starting my own practice. Unfortunately, I learned that the pediatrician’s office had shredded my chart the month before.

In B.C., doctors are legally required to retain medical records for a minimum of 7 years after the patient is last seen or after the age of 19 (i.e. age 26) whichever is longer.

This will change on June 1st. The College of Physicians and Surgeons of B.C. has changed its requirements to reflect changes to the Limitations Act. After that date, doctors must retain medical records for a minimum of 16 years from the date last seen or the age of majority.

Adults sometimes think about their medical records as something that will always exist just as some young people may assume that what’s on the internet will always be there. But just as your old facebook and blog posts will not remain online forever, your old charts may be destroyed if sufficient time passes.

For those who have moved and haven’t found a new family doctor, your old records may be gone before you have a chance to transfer them.

Your medical records belong to the physician or the facility where you have been treated. They include consultants’ letters, surgical reports, lab results and other investigations in addition to the clinical notes of the physician.

Those clinical notes are generally written with the sometimes illegible shorthand and abbreviations of physicians. They aren’t really written to be read by a layperson. Rather they are meant to provide a summary of each patient-doctor encounter written such that another physician could clearly understand what was said (the history), what was found (on examination), what was suspected (the differential diagnosis) and what was planned (the treatment, investigation and the follow-up).

If you walked into your doctor’s office and asked for your chart, it wouldn’t immediately be handed to you. Reviewing records – particularly the clinical notes – requires assistance from someone with a medical background. For example, if you read “S.O.B.” in your chart you might feel insulted though the doctor was simply using the accepted abbreviation for shortness of breath.

Though you don’t own your medical records, you have a right to the information contained within them. You should be cautious when signing off the right to share your confidential information with a third party.

When you – or someone else such as a lawyer with your written permission – requests the copying or transfer of your records, the doctor’s office will charge a fee that is generally reasonable and proportionate to the time required to review the records and produce copies.

The main reason medical records are destroyed beyond the legal retention limit is the amount of space required by the traditional paper chart. I’ve had some patients whose charts filled three file folders.

The problem of space will eventually be resolved with the widespread adoption of electronic medical records.

Coming up: What key information should you have from your medical records? What privacy issues arise from electronic chart?

Dr. Davidicus Wong is a family physician at the PrimeCare Medical Centre.  He is a regular Tuesday morning guest on Jill Krop’s AM/BC talk show on BC1.

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About Davidicus Wong

I am a family physician. I write a weekly newspaper column, Healthwise for the Vancouver Courier, Burnaby Now, Royal City Record and Richmond News.
This entry was posted in Medical Ethics, patient-doctor relationship and tagged , , . Bookmark the permalink.

2 Responses to Your Medical Records: What You Should Know

  1. Thank You Dr. Wong for this valuable information.- re Medical Records.

    Amelita

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