Medical Records - A Guide for Patients

What information should be in medical records?

Medical records should contain all of a patient's important medical history, such as illnesses and allergies.

The doctor should also record details of each consultation, including medications prescribed, procedures carried out, tests ordered and their results.

How confidential are my medical records?

Medical records should remain confidential between the patient and the doctor. The doctor's staff will need to see them. They may sometimes be required occasionally in a court. Otherwise, information from the records should not be made available without your written permission.

Who owns the medical records?

Medical records are the property of the doctor or practice attended by the patient, but the patient has a right to the information contained in the records. Therefore the physical record belongs to the doctor, but you are entitled to access the contents. This is backed by Commonwealth Privacy Legislation.

They concern my health - why don't I own them?

The records are the notes the doctor makes to assist the doctor. While they contain confidential information about the patient, they are made by the doctor and are the doctors property. By a patient's attendance to see the doctor, the patient has implicitly given him or her permission to take notes about the consultation.

Does that mean I have to stay with one doctor forever?

You have a right to attend the doctor of your choice, and also are entitled to leave one practice for another if you so wish.

Can I have copies of x-rays, pathology reports and other tests?

X-ray reports, pathology reports and anything else obtained at the request of a doctor usually remain the property of the doctor. Most doctors will be happy to provide the patient with copies of these reports, if asked. Payment of copying costs may be required. A patient is entitled to know what the results are.

Can I transfer my medical records to a new doctor?

While there is no legal obligation for doctors to transfer patient records there is a professional expectation that doctors will provide the new treating doctor with relevant details of your history upon request.

How do I arrange this?

The accepted practice is for the doctor who takes over management to seek relevant information from the former practice that will enable him or her to continue management. The usual practice is for the patient to ask your new doctor to arrange for the transfer of the records and to sign a consent form authorising this request.

Can the doctor charge for the handing over of medical records?

Some doctors may charge a fee for handling and copying their records, but this should reflect only the administrative costs involved. Your former doctor may charge you a fee for providing a summary, especially if your history is long and/ or complex.

What happens when a practice changes hands?

When a practice is disposed of, the doctor disposing of the practice should make reasonable efforts to ensure the maintenance of the records eg: by providing the records to the patient to whom they relate. The records may also be provided to another doctor identified by the patient at the request of the patient.

Unfortunately, there is no easy solution to the problem that arises when a doctor in solo practice dies suddenly (or leaves the practice without handover arrangements). Technically, his or her estate is liable for the safe-keeping of records, but in the turmoil of the circumstances, the family may not be able to handle such matters efficiently. Patients involved in such a situation should approach the estate and ask for the records to be sent to another doctor.

How long is a doctor required to keep my records?

Records must be kept for at least seven (7) years for adults and up to twenty-five (25) years for children from the date that the patient was last provided with medical treatment or services by the doctor or medical practice. Some doctors keep records indefinitely; others cull them regularly.

Can I ask for a personal copy of my records?

You are entitled to access the information contained in medical records, and it is at the doctor's discretion how he/she provides you with that access. Please contact the Office of the Federal Privacy Commissioner on 1300 363 992 for further details. If you require the records to take to your new doctor, it is advisable that you ask your new doctor to request this information from your previous doctor.

December 2004