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If you request to access your medical record and find incomplete, inaccurate, ambiguous, or outdated information, you can request the record be corrected.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!

 

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

Become a member

Become a member

The CAAP is a non profit organization that relies on the voluntary support of member organizations and individuals. By supporting its mission, members help create an influential network with a common vision where people can exchange ideas and collaborate. 

You can become a CAAP member too! 

It’s free.

I want to become a member of the CAAP – Capitale-Nationale

Member category

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Reporting

Reporting

Users can also report certain situations to the CAAP if they feel that the rights of one or more users have not been respected. Anyone can notify the CAAP of such a situation. If the person wishes, they can remain anonymous.

A good example of this type of reporting is the report filed by a Salvation Army point of service in March 2017 to raise awareness about a problem in a hospital emergency ward.

Thomas, a Salvation Army employee, contacted his local CAAP to ask for help filing a complaint against the hospital in question. The Salvation Army clientele are often homeless and have mental health and substance abuse issues. As a result, they are often uncooperative at the hospital, even if they require emergency care. Emergency room staff were not well equipped to deal with this type of clientele. They often let patients go without providing them with proper care. Thomas saw this as a form of systemic abuse.

Salvation Army users are very vulnerable and will not file complaints on their own. Since Thomas had observed how users were treated but had not experienced the situation himself, he didn’t know how to make his concerns known to emergency room officials The CAAP advisor offered to help him report the situation. Together, they documented the experiences reported by the Salvation Army in a report that Thomas submitted to the Service Quality and Complaints Commissioner of the hospital in question.

“It got people talking about the issue, identifying behaviours, and recognizing that our clientele is not treated in the same way [as other users]. The CAAP helped us structure our approach, know where we were going, and be more comfortable. We got a quick response because our document was taken seriously. The CAAP gave us credibility. We’d been trying to change things for years.”
– Thomas, Salvation Army case worker

The Commissioner took the report very seriously and measures are being put in place to improve the relationship between the hospital and the Salvation Army.

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Example of an individual complaint

Example of an individual complaint

Ms. Gauthier(1) requested a semi-private room when she was first hospitalized. However, she ended up in a room with a man and was very uncomfortable because she needed abdominal care. There were no curtains in between the beds because they had been removed for cleaning.

Ms. Gauthier was very disappointed with her experience at the hospital and wanted to file a complaint, but she did not know where or how to go about it. She had heard about the CAAP and decided to call to find out more.

The advisor who spoke to her explained that she would have to file a complaint with the Service Quality and Complaints Commissioner at the hospital where she had been treated and that she could make her complaint by phone or in writing. Ms. Gauthier didn’t feel comfortable phoning the commissioner herself. She told the advisor that she would prefer to file a written complaint, but that it seemed complicated and lengthy, and that she was a little discouraged. The CAAP advisor explained that she could help her draft her complaint. Ms. Gauthier was pleased and made an appointment with the advisor to proceed with the complaint.

During the meeting, the advisor explained to Ms. Gauthier that she was entitled to her privacy and dignity, even at the hospital, and that her desire to file a complaint was legitimate. The advisor took note of the events so she could prepare a letter for Ms. Gauthier to approve and sign. All Ms. Gauthier had to do after that was send it to the commissioner.

The advisor explained to Ms. Gauthier that the Complaints Commissioner would contact her to hear her version of events. She offered to help Ms. Gauthier prepare and even accompany her to the interview. This made Ms. Gauthier feel more confident. She could see that her request was being taken very seriously.

At the end of the commissioner’s investigation, Ms. Gauthier received a letter from the commissioner. The commissioner concluded that Ms. Gauthier’s complaint was justified and informed her that corrective measures had been put in place at the hospital.

According to the commissioner, temporary measures could have been taken to respect Ms. Gauthier’s privacy, such as putting up a portable screen or moving her to a different room. However, since a semi-private room does not exclude the possibility of sharing the room with someone of the opposite sex, Ms. Gauthier learned that she should have been informed of this possibility. In fact, the commissioner told her that she could have asked to change rooms. The Commissioner recognized that Ms. Gauthier had the right to be informed about all of these alternatives.

She therefore asked the hospital admissions manager to correct this by reminding the staff who manage beds to inform patients of all their options. In addition, a written reminder was also sent to all care teams to prevent a similar situation from occurring in the future.

In the end, Ms. Gauthier was able to see that her complaint had helped move things forward.

(1) Not her real name. Any resemblance to actual events experienced by actual persons living or dead is purely coincidental.

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