COMMISSIONER
FOR INFORMATION OF PUBLIC IMPORTANCE
AND PERSONAL DATA PROTECTION

logo novi


COMMISSIONER
FOR INFORMATION OF PUBLIC IMPORTANCE
AND PERSONAL DATA PROTECTION



logo novi

COMMISSIONER
FOR INFORMATION OF PUBLIC IMPORTANCE AND PERSONAL DATA PROTECTION

Are medical centres allowed to refuse to give a patient his own medical file which he wants to personally take to his new chosen physician at a different medical centre?

The Law on Health Care (Article 37, paragraphs 1 and 2) provides that data on health status and data contained in medical documentation are patients' personal data and are classified as confidential, in accordance with the law. Such data must be kept by all health workers and associates, as well as other persons employed in health care facilities, private practice, other legal entities carrying out health care activities in accordance with the law, compulsory health insurance institutions and legal entities carrying out the activities of voluntary health insurance which are covered by patients' health insurance and which have access to such data and need them to exercise their powers set by the law.

Further, Article 73, paragraph 3 of the Law on Health Care provides that health care facilities and their employees must safeguard the medical documentation of patients from unauthorized access, copying and abuse, irrespective of the form in which the data from the medical documentation are kept (paper, microfilm, optical and laser disks, magnetic media, etc.), in compliance with the law. Paragraph 5 of this Article stipulates that the types and content of medical documentation and records, the manner and the procedure of their keeping, the persons authorized to keep the medical documentation and to enter data, the timeframes for submission and processing of data, the manner of handling the data contained in the medical documentation of patients that is used for data processing, as well as other issues of relevance for keeping of medical documentation and records are regulated by a separate law. The laws which govern (albeit partially) the maintenance and keeping of medical records are the Law on Medical Records and the Law on Health Care Records. However, both of these laws were passed before the Law on Health Care and fail to address a number of important issues, such as e.g. the issue of transferring one's medical record from one medical centre to another. Thus, in order to answer your question, we must first determine who has a duty to maintain and keep medical records (including medical files). In other words: who owns the medical documentation?

Pursuant to Article 7 of the Law on Health Care Records, records are maintained by entering data in the main medical documentation and the ancillary record-keeping tools. The main medical documentation includes the following document: 1. medical file, 2. treatment protocol, 3. protocol for recording the results of medical work, patients who underwent surgery and deceased persons, 4. central records of persons placed at in-patient health care organisations, 5. medical history, 6. temperature, therapy and diet chart, 7. discharge sheet with epicrisis, 8. anaesthetic chart, 9. record book, 10. medicinal product consumption sheet. Ancillary record-keeping tools include: 1. card files, 2. daily records of visits and work, 3. current records of diagnosed diseases and conditions, 4. daily records of movement of patients within the hospital/inpatient clinic.

Pursuant to Article 8 paragraph 1 of the Law on Health Care Records, health care organisations are required to maintain the primary medical documentation, which includes, among other things, the patient's medical file. Medical files are maintained at the medical centres in charge of the relevant territorial unit for every person who receives health care in those centres, except patients in transit.

The legislative provisions quoted above show that the duty to maintain and keep medical records (including medical files) rests with health care institutions, in this care the medical centres. This means that the medical centre where a patient's medical file is kept has to send the medical file through official channels to the medical centre where the patient intends to transfer. In doing so, the medical centre concerned must take all necessary technical, human resources and organizational measures (Article 47 of the Law on Personal Data Protection) to protect data against destruction, loss and unauthorized changes and loss, which means it has to ensure safe and secure transport of the medical file to the receiving medical centre, while the receiving medical centre also has a duty to put in place all adequate safeguards when receiving the medical file. In the event of loss or destruction of a medical file, medical centres may be prosecuted for infringement.

However, as the right to data protection is a personal right (i.e. a right strictly associated with the person of the right-holder), the patient has the right to demand a copy of the medical file. In other words, according to Article 21 of the Law on Personal Data Protection, patients have right to a copy of data contained in medical documentation relating to them.

A request for a copy of medical documentation should be sent by registered mail with advice of delivery, in case a complaint has to be lodged at a later date. Namely, if the data controller (a medical centre or other health care facility) fails to issue o copy or rejects a request as unjustified, patients may lodge a complaint with the Commissioner. Together with such complaint, a patient should provide the request originally sent to the data controller, with evidence of delivery, as well as the text of the contested decision.

Monthly Statistical Report
in the field of Access 
to Information
and Personal Data Protection

31.12.2021.
PENDING: 3.118
DONE: 108.330

Read more...