Patient's right to medical file

Among the fundamental human rights of every natural person who becomes a patient and suffers from any disease or illness or requests or is provided with health care by a medical institution or health service provider, is the right to be treated with dignity during the provision of health care. This right is part of the right to life and is connected with the right to physical and mental integrity and security, as well as the right to respect for private life. In Cyprus, it is legally guaranteed by the 2004 Law on Entitlement and Protection of Patients' Rights, Law 1(I)/2005, which includes provisions concerning the right to health care and treatment, dignified treatment, access to health services, prohibition of adverse discrimination, right to information, confidentiality, maintenance of medical records and rights of the patient regarding medical records. In addition, provisions are contained regarding control mechanisms for the exercise of these rights, examination of complaints by a Commission, offenses and penalties.

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According to article 17 of the Law, the competent health provider, who can be a doctor, dentist, pharmacist or member of paramedical staff, must keep medical records showing the course of the patient's treatment. These records include detailed information identifying the patient and the relevant health care provider, as well as medical information regarding the patient's treatment, past medical history, diagnosis of the patient's current medical condition, and treatment provided to him.

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The patient has the right to information, access and objection in relation to information concerning him included in the medical records and when exercising these rights, the provisions of the Personal Data Processing of 2001 and 2003, as well as the Data Processing (Permits and Fees) Regulations 2002, article 18 of the Law. The patient's right of access to his medical records gives him the possibility to receive, directly or indirectly through his legal representative, information that is registered in those records or a copy or extract thereof.

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In relation to the question that the patient has the right to receive the first copy of his medical file free of charge, it was examined by the Court of Justice of the European Union in case C-307/22 issued on 26.10.2023. It involved a patient who asked his dentist for a copy of his medical record in order to establish her liability for errors she allegedly committed while providing him with dental care. The dentist demanded, however, that the patient be charged the costs of providing a copy of the medical file, as required by German law.

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According to the announcement of the Court of Justice of the European Union No.161/23, the patient, believing that he is entitled to a free copy, has brought proceedings before the German courts. In that context, the German Federal Court of Justice submitted preliminary questions regarding the interpretation of the provisions of EU law and specifically the interpretation of the General Data Protection Regulation (GDPR).

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In its decision, the Court, as stated in the announcement, recalls that the General Data Protection Regulation enshrines the right of the patient to receive, in principle, free of charge the first copy of his medical file. The controller can demand payment when the patient has already obtained the first copy of his/her data free of charge and requests a copy again. The dentist, in this case, must be considered responsible for processing the personal data of her patient. In this capacity, she is obliged to provide him with the first copy of his data free of charge. The patient is not obliged to justify his request.

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The Court also held that the national rules, even if they are intended to protect the economic interests of persons providing treatment, are not justified in providing for the patient to bear the costs of the first copy of his/her medical file. Furthermore, the patient has the right to receive a complete copy of the documents included in his/her medical file, when this is necessary to understand the personal data contained in said documents. The above right includes the medical file data containing information such as diagnoses, examination results, assessment by treating physicians and any treatment or operation provided.