“Doctor, can I see my chart?” The simple answer is, “Yes.” But it is actually a lot more complicated than that. I recently met with a patient who had a complex medical history, involving numerous specialists over the years. She hoped to seek a medical opinion from the Mayo Clinic for her ongoing unexplained neurological symptoms.
The Mayo Clinic instructed her to obtain all her medical records, past lab work, past consultations, and actual medical images on CD, and to send everything to them within 1 month. They informed her that she would have to repeat each lab test or image that she wasn’t able to provide at the Mayo Clinic, at her own cost. Of course, the patient’s first step was to immediately make an appointment with her family physician.
Upon reviewing her chart, a few issues appeared. One, she was relatively new to our practice and her previous GP had not sent us her entire medical record, only various parts of it. Second, some of the specialists she had seen did not forward all her labs or imaging to her GP, they only discussed them in their consultation notes. Third, for various reasons, she often had her CT scans done in Vancouver but her MRIs done in Surrey. To obtain the actual images on CD she would have to go to each hospital and request them, and each request could take up to 7 business days. For a patient who has limited mobility and who does not drive, this is a tremendously difficult task.
This patient’s frustration is understandable and I empathize with her situation greatly. Now that I am her family physician, our office has become responsible for her entire medical record. But the records in our office are often incomplete. It should not be such a difficult task for patients to access their own records, given that they are allowed to do so.
The responsibility for knowing your own health history should be shared between you as the patient and your health care provider. Steps are being taken to allow patients greater access to their medical records. For example, patients are now able to look up their own laboratory investigations. This increased access allows for more open conversations about the investigations ordered, but it can also create excessive worry and anxiety for patients. On the other hand, as health care providers, we often have to discuss sensitive, objective findings that may not necessarily align with a patient’s point of view. If the patient were to have full access to this information, it could damage the therapeutic relationship.
The issue of patients having access to their own medical records is complex, and I look forward to seeing how it evolves. But as our medical system moves toward comprehensive, patient-centred care, it is crucial that medical information be more accessible for both patients and providers.
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
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For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org