Medical records are extremely important in the health care field. Health professionals use medical records to make decisions about patient care and to manage that care. Medical records are effective communications tools that help doctors keep a close watch over their patients, no matter where they are.
A medical records is opened when a patient visits a health care institution or private clinic for the first time.
Medical records have personal information about a patient and information about the care the patient has received up to that point.
Any information that identifies a patient is considered personal information, whether it is on paper, computerized or in a voice recording.
Doctors and other health care professionals enter personal information in medical records to identify their patients. Personal information includes the following:
- date of birth
- health-insurance card number (medicare card number)
Doctors and other healthcare professionals also enter medical information in their patients' records:
- date of each visit
- other information that could complicate or affect the care they give
This article explains in a general way the law that applies in Quebec. This article is not a legal opinion or legal advice. To find out the specific rules for your situation, consult a lawyer or notary.