A health record is a collection of health data about an individual, prepared in connection with treatment or acquired from elsewhere in connection with treatment at a healthcare institution or the premises of a self-employed healthcare professional.
Health records shall include written descriptions or interpretations, images, including x-rays, graphical data, and video and audio recordings containing information regarding a patient's health and treatment provided by a healthcare professional or healthcare facility, and other necessary personal data.
A health record is stored in the health information system of healthcare facilities or on the premises of self-employed healthcare practitioners. These parties are the guardians of the health records. The supervisor of health records is a physician or another healthcare practitioner, if no physician is available, appointed by the guardian to supervise the entry and handling of information in health records and to ensure that they are consistent with the provisions of the Health Records Act. Healthcare
practitioners who work alone on their premises are deemed to be the supervisors of health records
they enters.
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A patient or their representative can access their health records in whole or part and be given copies on request.
Such a request shall be made to the health records supervisor. The supervisor must comply with patients' requests for copies of their medical records without undue delay. Should it be deemed not in the patient’s interest to gif them access to the health record in whole or in part or give them or their representative copy of the health record, the supervisor of the health record shall guide them of their right to refer the refusal to the Directorate of Health.
In the case of health data acquired from sources other than the patient themself or healthcare practitioners, the consent of the source of the information shall be elicited before the record is shown to the patient. Should such a source of information on a patient be deceased, or refuse on unreasonable grounds to give consent, the Medical Director of Health may decide that the patient or their representative be granted access to the data in question, in whole or in part.
A patient is entitled to information from the health records supervisor regarding which people have gathered information from their health record, where and when the data were collected, and for what purpose.
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For imperative reasons, a health records supervisor may grant a close relative of a deceased individual, such as the spouse, a parent, or a descendant, access to the deceased’s health records and give copies on request. When assessing whether access shall be granted to a health record of a deceased individual, consideration shall be taken to the relative’s interests requesting such access and to the wishes of the deceased if they are at hand.
A request for access to a deceased person's health record should be directed to the supervisor of the health record where the deceased received health care.
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Healthcare practitioners who are involved in a patient’s treatment and require their health records in connection with the treatment shall have access to the patient’s health records, with the restrictions arising from the provisions of the Health Records Act.
Health records contain sensitive personal information and are confidential. All healthcare practitioners must maintain confidentiality about all the matters stated in health records. The duty of confidentiality persists after the death of a patient and after cessation of the practitioner’s employment.
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Refusal of the supervisor of health records on a patient’s access to their health record may be appealed to the Medical Director of Health.
The same
applies to refusals of the supervisor of health records on granting close relative access to a health record
of a deceased individual or rejection of its copy. The procedure is subject to the provisions of the Administrative Procedure Act.
Decisions of the Medical Director of Health on access to health records are final at the administrative level and may not be appealed to the Minister.
