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- The competent health care services provider has a duty to keep medical records showing the course of the treatment of the patient. The administration of a medical institution or the health care services provider, as the case may be, shall have responsibility to keep and safeguard regular and updated medical records, in accordance with the Processing of Personal Data (Protection of Individuals) Law, 2001 and 2003.
- These records shall include detailed data identifying the patient and the competent health care services provider, as well as medical information on the treatment received by the patient, his/her previous medical records, as far as known, the diagnosis of his/her current medical condition and the treatment currently provided.
- The patient shall have the right to have access to data relating to him/her, which is contained in the medical records.
The patient’s right of access to his/her medical records shall enable him/her, directly or indirectly through his/her legal representative, to receive information contained in these records, or a copy or extract thereof.
Personal notes of the health care services provider shall not be part of the medical record. Consequently, patients do not have a right to access the personal notes of the health care services provider.
- The right of access may be limited, rejected or suspended by the person for the time being responsible for keeping the medical records if
- this information is likely to cause harm to the patient’s health;
- information on third parties may be disclosed and it is impossible to prevent access to such information;
- in case of genetic data, this information is likely to cause serious harm to consanguine or uterine kin or to a person who has a direct link with this genetic line.
- Minors and incapacitated adults do not have a right to direct access of the medical file. In these cases, the right to access is guaranteed through a legal representative without any specification.
- The patient’s rights of access to his/her medical records shall enable him/her, directly or indirectly through his/her legal representative, to receive a copy or extract thereof.
- The right to a medical file also includes the rectification of this information, their erasure and the blocking of the records by reason of inaccuracies and shortages.
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