The right to have access to medical records includes the right to get information in the records corrected.
What Can Be Corrected
These kinds of information can be corrected:
- inaccurate information,
- incomplete information,
- information that can be interpreted in more than one way (unclear).
It is also possible to ask for removal of outdated information (information that no longer accurately describes the situation) or information that is not relevant for the medical record.
Finally, patients can make written comments to put into their medical records to clarify information and complete the file.
Important! Not all information in medical records can be changed. Only mistakes involving facts can be corrected, for example, the injury was to the patient’s right leg rather than the left leg.
Medical opinions, interpretations and diagnoses found in medical records usually cannot be changed (for example, a patient’s symptoms).
Who Can Ask for a Correction
A patient can ask for a correction, which is also called a “request for rectification.”
These people can also ask for a correction:
- parents of a child under 18 years old,
- representative of a patient,
- heirs of a deceased patient (people entitled to inherit).
- liquidator (executor) of a deceased patient’s estate (A liquidator is the person or people named to settle the affairs of the person who died.).
In these situations, the person asking for the correction must show identification and prove how she is related to the patient.
How to Ask for a Correction
A request for correction is free, but it must be in writing.
Public Health Care Institution
If the medical records are in a public health care institution, the written request must be sent to the person in charge of the protection of personal information at the institution.
This person’s name and contact information are available from the institution. The Commission d’accès à l’information (access to information commission) also keeps a list of these people.
If the medical records are in a private clinic, the written request must be sent to the person who has the records, such as a doctor.
Time Limits for Answering a Request for Correction
The time limits are different for public institutions versus private clinics.
The person in charge has 20 days to answer a request for correction. This time limit can be extended by 10 days if the person in charge sends a written notice to the person who asked for the correction. If there is no answer by the end of this period, the person who asked for the correction should assume it has been refused.
The person who has the file has 30 days to answer a request for correction. If there is no response by the end of this period, the person who asked for the correction should assume it has been refused.
Request for Correction Allowed
If the request is accepted, a copy of the document with the changes is sent to the person who asked for the correction. The person who made the request can then see what was changed, added or removed.
Also, a notice is sent to anyone who received information that was later corrected, if that person got the information in the six-months leading up to the correction.
Request for Correction Refused
If the request for correction is refused, the decision must explain why it was refused. The refusal must also advise patients of the steps to take if they decide to challenge the refusal. The institution must also help the patient understand why the request was refused if the patient ask them to.
If corrections to medical records are refused, or there was no answer given by the deadline, you can contact the Commission d’accès à l’information (access to information commission) within 30 days of the refusal or expiry of the deadline to answer.
If the records are in a public institution, the request to review the decision is called an application for review. If the records are in a private clinic, it is called an application for examination of a disagreement.