you are in your daily practice time and again confronted with the desire of patients, their heirs or other parties and take in medical records of a patient access to want.
Put in this context, several questions: Who should inspect? As far as the right to inspect? Can I prevent this? The following is a brief overview of the most common situations.
first Who owns the medical records?
preliminary arises already the question of who the medical records belong. They are the property of the doctor, the person making it. The medical records do not only serve the statutory documentation requirements, but also the reminder of the physician, the evidence and possible quality control measures. The doctor can proceed with his property freely. He will be limited only by legal regulations. These are, in this connection, the storage requirement and medical confidentiality.
second The patient himself will inspect
If the medical records but are the property of the doctor, he must then give the patient insight? This question is clearly answered with "yes". This is both case law of the Federal Constitutional Court and the other prescribed in § 10 para 2 of the MBO for medical or § 12 para 4 of the MBO for dentists. The right of inspection results in particular from the right of patients to self-determination and personal dignity. You are therefore required in principle to the patient in your practice areas, the inspection grant. The patient can make in your practice at their own expense, copies. However, he has no right to the entrainment of the original documents.
includes principle, the right to inspect the entire medical records, including all-made notes on the clinical picture of Patients and identifying the patient is this case itself to meet the individual case, the balance between the right of patients to self-determination and the personal rights of the doctor who has an interest in the records which are only for him and not for the patient, to black.
The Federal Constitutional Court by order dated 09.01.2006 the right of patients assumed to have a considerable weight, so that the inspection will be rejected in all the notes only in exceptional cases. The problem arises in particular whenever the right of inspection meets with your medical concerns. This may be the case not yet confirmed diagnoses serious diseases, the risk of depression in psychiatric and his findings. Also in this case there is the fundamental right of access. However, flows into the consideration of whether the personal records of the "therapists" must be disclosed, the question of the possible adverse effects on patients with one.
The District Court of Bremen has committed in a partial decision of 25.07.2008 a therapist, the nachbehandelnden to provide medical consultation, so that decides what information the patient can get safely. The doctor was allowed to pre-treatment, however, previously black notes he had made for himself about the patient and were close on his own personality.
third Inspection by third parties
In the event that the patient's right of inspection to a third party (insurance company, pension insurance, health care professional) are contractually cedes that specified above.
So, the District Court Duisburg Judgement of 16.08.2007, that a doctor's obligation to the patient as possible to help, through the release of medical records to a specialist for further treatment sufficient enforcement colleagues. You should, however, the Medical Records of patients in each case carefully.
your duty of discretion is, moreover, to the police and the prosecutor. Again, the issue may be required only when there is an effective medical records. Otherwise, it requires a court order by the presumed will be the patients.
4th Inspection by the heirs
The inspection request of the heirs of a patient should be treated the same way as the inspection of any other third party. In a present of Medical Records, you are obliged to grant the inspection.
In the event that you are accused of medical malpractice, you should grant access because of the presumed consent of the deceased must be assumed.
5th Inspection by MDK and financial authorities
Compared with the MDK are you to transmit the data requested by law (§ 275 SGB V) required. It is important to the request of the inspection report to the eighth and surrendered only the requested documents. If not requested documents mitübermittelt, this is a breach of the duty of dar.
Compared to the tax authorities, you are obliged for reasons of public policy (decision of the Federal Administrative Court) to disclose. Medical confidentiality resigns here.
6th Conclusion
you should consult your notes always be aware that there are various inspection facilities. Especially in the foreign history, you should indicate that the patient could possibly inspect the records. Whether the statements of relatives / friends are still relevant then, but the question
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