How can a patient obtain their medical records?

How Can a Patient Obtain Their Medical Records?

Medical records are comprehensive documents detailing a patient’s medical history, diagnoses, treatments, and other relevant information. In medical malpractice cases, these records can serve as crucial evidence to support a patient’s claim. Yet, many patients are often uncertain about how to access these vital documents. 

This article offers insights into the legal rights and practical steps patients can take to obtain their medical records, ultimately aiding them in building a compelling case against potential medical malpractice.

Medical Records as Confidential Documents

Medical records are inherently confidential, and patients have exclusive access rights. Canada has robust privacy laws that protect individuals’ health information. Patients, parents, guardians, or representatives receive access.

The Role of Medical Records in Birth Injury Claims

Given the unique circumstances surrounding childbirth, medical records play a pivotal role in understanding the events leading to and during the birth process. 

From prenatal care to labour, delivery, and postnatal care, these documents detail an account of the events. Together, they contribute to a comprehensive case by offering objective evidence of the events leading to the birth injury. 

Critical Information in Medical Records

Medical records extend beyond handwritten notes and consultation reports. Diagnostic imaging, fetal heart monitoring records, and pathology slides are integral components, often crucial in investigating medical malpractice claims. It’s imperative to recognize that a child born under medical care will possess a separate medical record from the mother.

Obtaining Medical Records: A Step-by-Step Guide for Patients

Here’s a general guide to help you obtain medical records for a potential medical malpractice claim:

Identify the Healthcare Provider

Determine which healthcare provider or facility has the relevant medical records. It could include hospitals, clinics, obstetricians, midwives, or other healthcare professionals involved in prenatal care, labour, and delivery.

Initiate the Request

Patients or their legal representatives must provide written authorization and consent to obtain medical records. Your lawyer can help you draft the necessary documents. Write a formal request for medical records, including the specific time or incidents you are interested in. 

Address the request to the custodian of records at the healthcare institution. You may need to use a specific form provided by the institution or your lawyer.

Understand Privacy Laws

Familiarize yourself with federal and provincial privacy laws, like the Personal Information Protection and Electronic Documents Act (PIPEDA), and the national or provincial health information protection legislation. Ensure that your request complies with these laws.

Pay Any Required Fees

Securing a copy of your medical records is not without a financial implication. Charges vary among providers, and opting for electronic records to mitigate additional costs is advisable. Customers can send concerns about charges through a complaint to the Information and Privacy Commissioner of Ontario (IPC).

Legal Proceedings

Once you receive the medical records, carefully review them with your lawyer. Based on their advice and the information in the medical records, decide whether to proceed with filing a medical malpractice claim. Your lawyer will guide you through the legal process, including serving notice to the defendant and filing necessary court documents.

Accessing Medical Records for Children

In cases involving minors, specific individuals, including parents and legal guardians, are authorized to request medical records under PHIPA. Understanding these nuances is crucial when pursuing claims related to children.

Patients aged 14 or older have the fundamental right to access their medical records. They also possess the authority to authorize or deny access to others. It marks a crucial age where minors can independently decide about their healthcare and limit parental access to their medical history.

How Long Are Medical Records Retained?

Medical professionals must follow provincial or territorial laws on retaining clinical records. The CMPA advises keeping medical records for at least ten years (16 years in British Columbia) from the last entry or, for minors, ten years (16 years in British Columbia) from reaching the age of majority. 

It applies to obstetrical care records kept for at least ten years from when the infant reaches or would have reached the age of majority. These retention periods are crucial for legal defence, as medical records are vital evidence in medical-legal issues. 

Records for Deceased Persons

When someone dies, their heirs and family can access their medical records with limited information under certain conditions. Heirs, in particular, must substantiate their status with proof and submit a detailed request justifying their need. It might be from reasons like pursuing a medical malpractice lawsuit against a healthcare facility.

Timelines for Obtaining Medical Records

Provincial or territorial laws related to protecting personal health information govern response time. Ontario’s Personal Health Information Protection Act (PHIPA) stipulates the 30-day timeframe. 

Seek Legal Assistance If Necessary

Seeking legal assistance is advisable if you encounter challenges getting medical records or believe your request is unduly delayed. A lawyer experienced in medical malpractice can guide you through the process and advocate on your behalf.

Medical Malpractice Case Evaluation

Once the necessary medical records are in hand, a birth injury lawyer conducts an examination, seeking essential information to build a comprehensive case.

Timeline of Events

A chronological record of events in medical records is valuable for assessing the sequence of medical care. This timeline helps determine if there were deviations from standard practices.

Identification of the Circumstances Leading to Medical Care

The birth injury lawyer scrutinizes the records, focusing on specifics that led you under the healthcare provider’s care. It involves understanding the circumstances that initiated the medical care and laying the foundation for the legal evaluation.

Assessment of Harm and Its Extent 

Examining the records delves into indications of harm and its extent. The lawyer identifies details highlighting the impact on your well-being, forming a crucial basis for determining the damage’s severity.

Detecting Alterations or Gaps in Records

A critical part of a review involves identifying any signs of tampering, changes, or gaps in the medical records. It includes assessing completeness and ensuring that vital information isn’t missing, providing a comprehensive understanding of your medical history.

Expert Witness Support

Medical negligence lawyers rely on medical records to consult with experts who can analyze the provided care and testify about deviations from the standard of care, causation, and the resulting damages.

Seeking Guidance from a Birth Injury Lawyer at Sommers Roth & Elmaleh

If you or your child has suffered harm or trauma due to medical errors, the seasoned birth injury lawyers at Sommers Roth & Elmaleh are here to guide you through the process. We can obtain your medical records and pursue the justice you deserve. 

Our commitment centers around championing the rights of individuals, particularly infants, who have endured birth injuries due to medical or nursing negligence

Call Sommers Roth & Elmaleh at 1-844-777-7372 for a free consultation, or contact us here.

Disclaimer and Liability Exclusion

The information on this page is provided for general information purposes only. It should not be construed as legal advice. It does not constitute legal or other professional advice or an opinion of any kind. Readers should seek specific legal advice regarding any specific legal issues. We do not in any way guarantee or warrant the accuracy, completeness or quality of the information on this page. The posts on this page are current as of their original date of publication, but they should not be relied upon as timely, accurate or fit for any particular purpose.

Accessing or using this web site or the content herein does not create a lawyer-client relationship.

This page may contain links to third party web sites. We are unable to, and do not, monitor and guarantee the quality of the information disseminated and accessible through those links, which are provided for convenience only. We do not endorse the information contained in linked web sites nor guarantee its accuracy, timeliness or fitness for a particular purpose.

    If you have been affected by medical malpractice anywhere in Canada contact us for a free consultation.
    You pay us nothing unless we win.



    A lawyer from Sommers Roth & Elmaleh will be in touch with you as soon as possible. Please note that no lawyer-client, advisory, or fiduciary relationship is created by your inquiry. All information provided is confidential.

    The above information is not legal advice. Past results of cases and recoveries by our medical malpractice lawyers against hospitals, doctors, midwives, nurses and other healthcare professionals are not necessarily indicative of future results. The amounts recovered and other litigation outcomes will vary according to the facts in individual cases.


    See Our Lawyer's Reviews