What is a Medical Record?
A medical record is made up of documents containing medical information regarding your health care. Your medical report belongs to the person or institution that wrote it. Although you cannot take your record without the writer’s permission, you do have a right to access to your record and can enforce this right by court order. Some other organizations, including the government, also have a right to access to your file. Know your rights Health informatio Act (HIA). If you wish someone to have access to your file, you may give consent in writing. In general, however, the record should be kept private and confidential.
By law, your physician must keep records of all in-patients for seven to ten years. Some physicians, however, keep their records for a much longer time than this.
Patients have the right to the information their medical records and may request that their medical record information be released to themselves or other third parties for various reasons. The Release of Health Information Brochure (PDF) provides patients with information on release requirements and how to request release of their health records to common third parties for various reasons. Records of the care patients receive at Caleo Health are kept in strict confidence and are not released without the patient’s written consent, except as required by law.
physicians can refuse to disclose the information in the record to the patient, but only if they reasonably believe there is a significant likelihood that disclosing the information will have a substantial adverse effect on the patient’s physical, mental, or emotional health, or cause harm to a third party. The onus in such circumstances is on the physician to justify denying a patient access to information in their medical record.
Disclosure of Health Information Under the Health Information Act
Consent is required under the HIA to disclose information about a patient, you or someone legally authorized to act on your behalf will be required to provide Caleo with your written consent prior to releasing the specified health information. Caleo has specific requirements for what is contained within a valid consent to disclose health information.
Transfer of Records
Information in medical records may need to be transferred between physicians such as when a patient transfers to another doctor. A copy of the information may be sent directly from the former physician to the new one, or the patient may request to receive the record. The CMPA recommends that physicians not release the original files. Instead, the pertinent information may be transferred by other means such as a report summarizing the relevant entries in the record, or a photocopy or scan of the file may be provided if requested. By law, your physician must keep records of all in-patients for seven to ten years. Some physicians, however, keep their records for a much longer time than this.
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Protected Health Information (PHI)
The Privacy Rule protects all “individually identifiable health information”
held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral.