Doctor’s Notes Are Your Business Too
Ever wonder what your doctor is writing about you when he scribbles his notes in your medical file?
A San Fernando Valley woman wants to know if her doctor “owns” her medical records. More important, she says, she wants to know whether she has a legal right to see them and take home a copy.
Technically speaking, the doctor owns the medical records. It is his work product, so to speak. The records have always been subject to court order or subpoena if they were needed in a legal proceeding. But under a state law passed in 1982, every patient has certain legal rights to the records.
Complete Record
In general, a patient has the right to inspect the records and receive a copy, or if the doctor or hospital won’t produce them, then the patient must be given a fair and complete summary of the record.
The law is called “Patient Access to Health Records,” and you can find it in your local law library beginning at Section 25250 of the California Health and Safety Code. It states that every person has the “right of access to complete information respecting his or her (health) condition and care provided.”
The law applies to physicians, podiatrists, dentists, optometrists, chiropractors, marriage counselors, clinical social workers, hospitals, clinics and nursing homes. All of these “health-care providers” have to let you see your records.
You must make a written request for the records and are required to pay the “reasonable clerical costs” of finding and making them available. Your doctor has five business days from receipt of your request to allow inspection of the records, and 15 business days to give you photocopies. When you inspect the records, you can bring one person to assist you.
You may be charged up to 25 cents per page for the copies and up to 50 cents if the records are on microfilm. That’s in addition to the clerical costs for finding the records. The law also requires that you specify exactly what records you want when you are ordering copies. (You may want to inspect them before you ask for copies.)
If your doctor or hospital does not want you to see your actual records, they do have an option under the law. They can prepare a summary of the record, which must be completed in most cases within 10 days of the request. The summary cannot be sketchy or incomplete. The law contains a long list of the items that the summary must contain, including diagnosis, reports of procedures, treatment plan and prognosis, among others. The doctor can charge a reasonable fee for the time spent preparing the summary, but the Legislature said that summaries should “be made available at the lowest possible cost to the patient.”
There Are Exceptions
As with all laws, there are exceptions. The law is not applicable to health-care practitioners who are not licensed to practice in California. So your old New York doctor won’t be bound by the law. And you cannot obtain copies of X-rays and similar tests if your doctor will send the originals to your new doctor.
Anyone over the age of 18 has the right to use this law. Minors may also inspect records but only those concerning health care they have the right to authorize themselves. Parents and guardians have the right to inspect and copy the records of their children and wards, unless, the law says, it would have a detrimental effect on the professional relationship between doctor and child or it would impair the minor’s physical safety or psychological well-being.
What happens if the doctor refuses to comply with your request? There are two things you can do. First, you can sue. The law authorizes legal action to enforce the health-care provider’s obligations.
You may be able to obtain an injunction--where the court orders the doctor to turn over the records--which can sometimes be available on an expedited basis (meaning you won’t have to wait years to have your day in court). But then you’ll have to hire a lawyer and pay legal fees.
You may not be stuck with the fees forever, because the law gives the judge discretion to make the losing party pay “reasonable attorney’s fees” to the winning party. However, because it is discretionary, there is no guarantee of winning the fees even if you win your case, and even then, the judge could award less in fees than what you actually paid your lawyer.
There is another, more practical, solution. You can complain to the state agency or board that licenses your doctor. Under the statute, any doctor who willfully refuses to comply with the law is “guilty of professional misconduct” and subject to disciplinary action by the appropriate agency.
Statute Violation
If a hospital or nursing home refuses to cooperate, you should report its refusal to the city attorney. Willful violation of the statute by a health-care institution is an “infraction” punishable by a fine not exceeding $100.
For a more detailed understanding of this law, try reading it yourself in the law library. It’s pretty straightforward. Or call Tel Law in San Bernardino at (714) 824-2300 and ask to hear the newest tape, No. 247. You’ll have to pay the toll charge for the call, if there is one.
After you use this law and once you receive your medical records, you still may not be completely satisfied. The law does not require your doctor to write in understandable English, nor does it require that his handwriting be legible.
Attorney Jeffrey S. Klein, a member of The Times’ corporate legal staff, cannot answer mail personally but will respond in this column to questions of general interest about the law. Do not telephone. Write to Legal View, You section, The Times, Times Mirror Square, Los Angeles 90053.
