Editor's Letter

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Pat Rich
Editor-in-Chief
pat.rich@cma.ca

The more information your doctor has about your health and medical conditions — and the more accurate it is — the better the position she or he is in to treat you. Your physician should have a complete record of your family’s medical history, all conditions you’ve had in the past or are dealing with now, and any medications you are currently taking. It’s up to you to make sure your record is accurate. Ideally now, you should be able to provide any new doctor with at least a summary of the care you have received from previous physicians.

Full disclosure on your part is also important. Keeping information from your doctor — such as any herbal remedies you might be taking or your failure to take all of a prescribed medicine — means that he or she won’t be working from the most complete information. And not disclosing the use of herbal remedies can put you at risk for unpleasant or even dangerous interactions with various prescription drugs.

A complete and accurate medical record doesn’t come together magically — even in the 21st century when pieces of information can be linked together electronically. If you are treated by more than one doctor or get care in a walk-in clinic or an emergency room, don’t assume that this information will automatically find its way into the medical record held by your family doctor. Your physician will receive the results of any tests he orders, but this is the only instance in which you can assume with some confidence that information is flowing into your doctor’s office.

So if you do need medical care outside of your family doctor’s office, ask that a copy of the outcome be transmitted back to your physician, even if you have to take it there yourself. Electronic health records promise to make this transfer more seamless, but we are not quite there yet.

It’s also important to know that all of the medical information you provide to your doctor belongs to you. So you have a right to a copy of whatever record has been compiled. Your right to examine and get a copy of your own medical record was enshrined in law by the Supreme Court of Canada in 1992. This is also Canadian Medical Association policy for its members.

You don’t own the original record prepared by your doctor —  that is the property of the physician. In order to keep their medical licences, doctors are required to keep medical records on all of their patients and produce them as required to monitor their performance or deal with complaints.

Doctors also have a right to charge reasonable fees to make a photocopy of your medical record, so you could pay 75 cents per page. With some records comprising dozens of pages, this can add up. But that doesn’t alter the fact that, barring very unusual circumstances in which providing you with your complete record may cause harm to you or others, your doctor should be prepared to provide a copy of your record and explain it to you if asked. Such an exception might be a patient with a severe mental illness who the doctor fears may be unable to correctly interpret the information about his or her diagnosis and treatment.

Another very important point about your medical record is that it is confidential. Your doctor will not share this information with others unless it is necessary for the provision of care, or if there is a legal requirement to do so — such as the reporting of suspected child abuse.

To take control of your own health, you may need a copy of your medical record. Keep in mind that you must ensure that it is as complete and accurate as possible if you are going to receive optimal care.