How do I request my medical records and what do I do if they refuse?

Question

José Manuel Alburquerque · Accepted Answer

Request your medical records in writing, keeping proof of submission, from the patient services department of the hospital or clinic, or from the doctor directly if it is a private practice. You are entitled to a copy and the first one is free, even if you want it in order to make a claim. The hospital or clinic must reply within one month, a period it can extend by two further months if the request is complex. If you are not given them, you can complain to the data protection authority or ask the judge to order them to be handed over before proceedings are brought. How to request your records In writing, to the patient services or citizen services department, with a copy of your identity document. Many hospitals and clinics have their own form. You do not have to explain why you want them. Ask for a full copy covering all episodes of care, including the imaging tests, the nursing records, the anaesthetic and birth records, the signed consent forms and the discharge summaries. If you do not specify this, you may be given only the main reports. Hand in your request at the official registry of the hospital or clinic, or send it by some other means that records the date. Keep the proof of submission, because the time limit for replying runs from that day. Someone else can request them on your behalf if they can show that they represent you, for example with an authorisation signed by you. If you are treated by the Catalan public health service, you can see some of your reports on “La Meva Salut”, the online patient portal, but not your complete records. What they must give you The first copy is free, even if you want it in order to make a claim against the doctor. The Court of Justice of the European Union said so in 2023. For further copies they can charge you a reasonable fee. If you need it to understand your records or to check that they are accurate and complete, you can insist on copies of the full documents and not a summary. Information about other people may be left out, as may subjective notes, which are the personal impressions that the professional writes down and is entitled to keep back. If the patient has died, the records can be requested by people linked to the patient by family or close personal ties, unless the patient had expressly forbidden it. They are not given anything that affects the patient's privacy, the subjective notes or anything that would harm other people. The hospital or clinic must keep them. In Catalonia, the most important documents, such as consent forms, discharge and operation reports, the birth record and the anaesthesia details, are kept for at least fifteen years from discharge. The rest can be destroyed after five years, so do not delay in requesting them. If you are not given them or something is missing Complain to the data protection authority. If it is a public healthcare centre in Catalonia, such as a hospital run by the ICS, the Catalan Health Institute, or by a public consortium, or a private centre that treated you at the expense of the Catalan public health service, complain to the “Autoritat Catalana de Protecció de Dades”, the Catalan data protection authority. If it is a private clinic or practice that you went to privately or through your private medical insurance, complain to the “Agencia Española de Protección de Datos”, Spain's data protection authority. Ask the judge to order them to be handed over before you sue. The law expressly provides for this step before proceedings, known as a “diligencia preliminar” (pre-action disclosure). If proceedings have already begun, your lawyer can ask the judge to order the hospital or clinic to produce whatever is missing. In a claim against the public health service, the records form part of the file. Records that cannot be found or are incomplete usually count against the hospital or clinic at trial. While you wait for the copy, the time limit for claiming keeps running. If it is close to expiring, make a written claim without waiting until you have it.