Requests involving medical records

Request for access to medical records

The information on file may answer questions you have about care and services provided and may help you understand a situation that concerns you.

If you are 14 or older, you have the right to:

  • Confidentiality
  • Access your records in a timely manner
  • Have your records transferred
  • Be assisted by a professional
  • Appeal the decision if you are refused access to your records

The CAAP can help you draft your request to access your records. Since you usually get a copy of your file or part of it, there may be photocopying fees associated with your request. You can ask to be notified of any costs before the documents are copied.

If your request is denied, you have the right to seek remedy from Commission d’accès à l’information.

Request to correct information

If you request to access your medical record and find incomplete, inaccurate, ambiguous, or outdated information, you can request the record be corrected. Such a request must be about facts, for example if the doctor wrote down that they operated on your right hand when it was your left hand, a date is wrong, or you are no long taking certain medication.

In principal, professional opinions in your records cannot be modified. For example, a patient’s symptoms, a clinical hypothesis, an assessment, or medical diagnosis. You can, however, get a second opinion for another professional which would be recorded in the file. You can also add notes to your records about things you find inappropriate.

Requests should be addressed in writing to the person responsible for access to documents (commonly referred to as “archives”) at the facility holding your records. We can help you draft your request. Call us!

 

Why file a complaint?

Why file a complaint?

 “What’s the point of filing a complaint?”

We get this question a lot at the CAAP. Many people feel powerless in the face of our vast and complicated healthcare system.

The complaint examination process  is a fast and free way to correct situations, prevent mistakes from happening again, understand what has happened, or sometimes even compel professional orders to remind their members about best practices. Filing a complaint is an act of citizenship that is worth promoting, because rights only truly exist when they are respected and upheld.

It’s a win-win situation!

It’s important to understand that the complaint process is not a “punitive” process, but a “corrective” one. Of course, there is nothing to prevent you from taking legal action at another time, but the CAAP does not intervene in such proceedings—you will have to call a lawyer.

Network professionals and practices may seem untouchable because users are afraid of being judged or facing retaliation. But system stakeholders work for the users and have a legal responsibility to be impartial. 

Just remember you can ask the CAAP for help with the complaint process at any time.

Your rights within the network

Your rights within the network

Your rights within the network

Taking into account the provisions* and the human, material, and financial resources available to the institution, YOU HAVE THE RIGHT:

  • To be treated with courtesy, fairness and understanding, and with respect for your dignity, autonomy, needs, and safety
  • To be informed of the health and social services and resources available in your community and of how to access them
  • To receive appropriate scientific, human, and social services on an ongoing basis in a safe, personalized manner
  • To choose the professional and institution from whom or which you wish to receive health or social services
  • To receive the required care for your condition
    Everyone whose life or bodily integrity is in peril is entitled to receive the necessary care. Institutions are responsible for providing such care when requested to do so.
  • Be informed of your state of health and welfare
    You have the right to be informed of the various options open to you and of the risks and consequences generally associated with each option before you consent to care. The same applies to any accident that occurs during the provision of services that may impact or has impacted your health or wellbeing. You also have the right to be informed as soon as possible of any measures taken to remedy such consequences, where appropriate, or to prevent such an accident from happening again.
  • To give or withhold consent
    No person may be made to undergo care of any nature, whether for examination, specimen taking, treatment or any other intervention, except with their consent. Consent to care or the authorization to provide care shall be given or refused by the user or, as the case may be, by their representative or the court.
  • To participate in any decision affecting your state of health or welfare.
    You have the right to participate in the development of your intervention plan or your individualized service plan. The same applies to any modifications made to such plans.
  • To be accompanied and assisted by a person of your choice
    when you want to obtain information or take steps in relation to any service provided by or on behalf of an institution or by any professional practising their profession in a centre operated by the institution.
  • To be represented if you are a minor or an unfit adult
  • To stay at a hospital or institution if your state of health requires it
  • To receive health and social services in English if you are an English speaker
  • To seek remedy against an institution, its directors, employees or attendants or a professional by reason of a professional or other fault
    In no case may such remedy be waived.
  • To access your records, which are confidential

Private seniors’ residences and drug and gambling addiction resources must also meet certain certification criteria and standards. Learn more here.

Users should participate in care and services that concern them as much as possible and use such services in a judicious manner.

*legislative and regulatory provisions related to the organization and operation of institutions

From the Act respecting health services and social services, R.S.Q., chapter S-4.2, October 30, 2012, p. 2–6

Independent of the health and social services network

Le CAAP est un organisme communautaire, financé par le ministère de la Santé et des Services sociaux. Nous déterminons de façon autonome notre mission, nos approches, nos pratiques et nos orientations. Il s’agit d’un organisme à but non lucratif (OBNL) dirigé par un conseil d’administration élu par nos membres.

Ainsi, nous accompagnons et informons nos usagers en toute indépendance des commissariats aux plaintes et autres composantes du réseau de la santé. Nous sommes au service des citoyens.

Le rôle du CAAP dans le réseau de la santé et des services sociaux est reconnu dans les articles 76.6 et 76.7 de la LSSSS.

Excerpt from the Act respecting health services and social services (ARHSSS)

76.6. Le ministre doit […] confier à un organisme communautaire de la région le mandat d’assister et d’accompagner, sur demande, les usagers qui y résident et qui désirent porter plainte auprès d’un établissement de cette région […].

76.7. [L’organisme] a pour fonctions, sur demande, d’assister l’usager dans toute démarche qu’il entreprend en vue de porter plainte auprès d’un établissement, d’une agence ou du Protecteur des usagers et de l’accompagner pendant la durée du recours, y compris lorsque la plainte est acheminée vers le conseil des médecins, dentistes et pharmaciens d’un établissement. Il informe l’usager sur le fonctionnement du régime de plaintes, l’aide à clarifier l’objet de la plainte, la rédige au besoin, l’assiste et l’accompagne, sur demande, à chaque étape du recours, facilite la conciliation avec toute instance concernée et contribue, par le soutien qu’il assure, à la satisfaction de l’usager ainsi qu’au respect de ses droits.

Source : Publication Québec