The Patient's Right to Keep Their Medical Record
Discover more about a basic right we have as patients: access to our information and medical records. All of this is legally regulated in Mexico by NOM-168.
Numerous efforts have been made today to protect and guarantee people's rights when using healthcare services. We might think our rights are limited to receiving quality care, but there are actually other priority aspects we should be aware of.
Patients' Rights
One of these is the right to privacy and the protection of our personal data. Healthcare institutions are obligated to protect our information, and to ensure that it is not accessed by private individuals or other institutions with no legitimate claim to it.
Secondly, we have the right to receive a copy of all the information a healthcare institution holds about us, to verify the purpose for which it was collected, and, if necessary, to have it corrected or updated.
Legal Protection for Patients in Mexico
Furthermore, in Mexico the Federal Law on Transparency and Access to Public Information establishes that individuals have the full right to access their medical records.
However, Norma Oficial Mexicana 168-SSA1-1998 del Expediente Clínico (Mexican Official Standard on Clinical Records), better known as NOM-168 (Diario Oficial de la Federación, September 30, 1999), establishes that clinical records are the “property” of the institution providing the healthcare service, allowing only for the possibility that the patient may obtain a “summary” of the clinical data.
The patient's right of access to the documentation on their clinical history will have as its limit the right of third parties to privacy and to the confidentiality of the data contained in clinical records.
Can a Clinical Record Be Deleted?
Taking the above definitions into consideration, we might ask whether it is possible to delete our clinical history from a particular institution.
The answer is that, with regard to data protection, there is a right to erasure of information and personal data at the data subject's discretion.
But in the healthcare field, this right to erasure is more limited. Strictly speaking, healthcare personnel may decide on the deletion of health information, since the content of the clinical record is used, besides for the proper provision of care to the patient, for judicial, epidemiological, public health, research and/or teaching purposes, which are linked to the public interest or compliance with legal obligations.
Possibility of Access to the Clinical Record of a Deceased Person
In the event that we need clinical information about a deceased person, only the following is taken into strict consideration: access to the clinical history of deceased patients will be granted to persons connected to them, whether for family reasons or in fact, unless the deceased had expressly prohibited it and this can be proven.
Information that affects the privacy of the deceased will not be disclosed, nor will the professionals' subjective notes, nor information that would harm third parties.
Can Anyone Access the Information in a Clinical Record?
A quick answer is: no. In the case of healthcare professionals, they may only access a clinical record when doing so is warranted and considered necessary to carry out their work.
However, they may not access medical records out of mere curiosity, or to pass on a patient's information to an acquaintance. This type of conduct may be subject to legal sanctions.
Acts that are not only classified as violations of data protection regulations also appear in the Penal Code itself as the crime of disclosure and discovery of confidential data, in cases where a healthcare professional unlawfully accesses a patient's health data.
The clinical record is used solely for the purpose of ensuring appropriate care for the patient, and therefore the facility's healthcare professionals will have access to it as an essential tool for their work.
As for the administrative and management staff of healthcare facilities, they may only access the clinical record data related to their own duties, while committing at all times to uphold the duty of confidentiality and complete secrecy.
The proper handling of information and the clinical record of each patient require respecting each person's privacy, in the form of the confidential nature of all data concerning their health. All of this is protected within the framework of the law.
This is why healthcare facilities must have protocols in place to ensure that access to such information is carried out in a strictly legal and professional manner.
References
- Legal regulation of clinical data in Mexico. Medigraphic.
- Access to the clinical record. Archivos Judiciales. UNAM.
- Right of access to the patient's clinical record. Law Trends.