Do you have Your information?
I am often asked: “Am I allowed to request information from my health record?”
Patient records can include emergency room reports, operative reports, specialist consultation reports, test results, discharge summaries and more.
“Paper files of medical records” by Newtown graffiti is licensed under CC BY 2.0
In short, patients are absolutely allowed access to information stored in their health record, which includes emergency room reports, operative reports, specialist consultation reports, test results, discharge summaries and more.
Beyond being permitted, I think it’s a good idea for individuals to access their health information, because this is one way to promote patient engagement. Research shows that engaged patients better understand what they can do to help themselves, which creates benefit for both the patient and the healthcare system.
Likewise, the President of the Alberta Medical Association and the Registrar of the College of Physicians and Surgeons of Alberta recently re-iterated that their organizations support patient access to health records. They see this as one way to promote better communication and continuity of information between all involved parties – all doctors with the patient, as well as with caregivers.
What could a patient do with that information? Here are a few possibilities:
Some want to review their treatment or recovery plan to make sure they follow the plan well.
Some want information from their health records to help them to reconstruct their medical history accurately.
Some want insight into treatment or surgery that they received while they were sedated or taking medication that clouded their focus.
Some want to understand what details doctors are sharing – and sometimes not sharing – with one another.
Some want to share their health information with doctors in different provinces or states (if a doctor in Alberta is registered to use Netcare they can view your electronic health record, but doctors outside the province cannot register to use it; likewise, treatment received outside Alberta will not be recorded in Netcare).
Copies of health records help some patients to share information about treatment received in different provinces or states.
“AB Canada province” is released into the public domain.
The next natural question is “How do I access information in my health record?”
Here are a few ways that Albertans can get information from their health record:
Ask your doctor for a printout of recent test results or reports. When you ask for recent information, you may get a copy at little to no cost, with little to no wait.
Note: in my experience, specialists do not provide a report after a consultation – though they may share test results; rather, the specialists have advised to ask for a copy of the report they send your family doctor (or whoever referred you to see the specialist).Sign-up for MyHealth Records – recently released by Alberta Health Services – to view online your recent blood test results, prescriptions, and immunizations.
Submit a formal request to the clinic or hospital that provided treatment. Alberta Health Services has published online the Health Information Access Request form, as well as the general process to submit a request. This is the appropriate process for requesting older health information; it’s worth knowing that the formal request process comes with a cost and waiting period, since it takes time to find and to copy the older, stored information.
Note: very old records may not exist anymore, especially if you have an inactive file at the treating clinic or hospital. Doctors and physicians must keep patient records for at least 10 years, and older information may put into long-term storage or may be destroyed.
While gaining information is empowering, sometimes accessing the information in your health record can create new questions, like “what does it mean” or “what do I do with this now”. If you are asking those questions, or if you feel overwhelmed with the information request process, call or e-mail us at Navigate Your Health. You will receive support from a trusted health navigator and advocate to make sense of the information, and to navigate the next steps in your health journey.