As a patient, you have a statutory right to access your medical records. This right is laid down in the Medical Treatment Contracts Act (WGBO). Yet in practice, many people do not know how to request their records or what their precise rights are. In this blog, we explain why your medical records are so important, what you may request and how you can have errors corrected.
Why your medical records are important
Your medical records contain everything about your treatment: examinations, diagnoses, operations, medication, specialist letters and notes of consultations.
These records are of great importance, not only for your care, but also if something goes wrong. In the case of a possible medical error or in a personal injury case, the records constitute the most important evidence.
Read more about this in our blog Medical liability in the Netherlands: patients' rights and the route to compensation.
Your statutory rights under the WGBO
Every patient is entitled under the WGBO to:
Access to his or her complete medical records;
A copy of all documents;
Correction or deletion of incorrect data;
Destruction of the records upon request.
The healthcare provider must retain the records for at least twenty years, but if you wish, you can request earlier destruction. Only in exceptional circumstances (such as overriding medical interest or the interests of third parties) may the healthcare provider refuse your request.
How do you request your medical records?
You can request your records by sending a written or digital request to the healthcare provider or hospital. Clearly state that you wish to access or receive a copy of the complete records and, if applicable, indicate the period concerned.
The healthcare provider is obliged to respond within one month.
You can usually receive the records via the patient portal, by post or via a secure email. Requesting your records is free of charge.
What may the healthcare provider refuse?
In principle, the healthcare provider must provide you with all data relating to you. However, access may be refused in certain cases, for example:
If the privacy interest of a third party would be compromised (such as a family member or colleague);
If access would seriously harm your own health (for example in the case of psychiatric issues);
If the records also contain information about others who do not wish it to be shared.
If you are uncertain whether a refusal is justified, you can file a complaint with the healthcare institution or the Dutch Data Protection Authority.
Right to correction or supplementation
If there are errors in your records, you have the right to correction. This applies to factual inaccuracies, such as an incorrect date, wrong medication or an incorrect diagnosis.
The healthcare provider must inform you within one month whether your request is granted. If the doctor refuses, you can request that your own statement or perspective be added to the records.
Destruction of your records
You can also request that (parts of) your records be destroyed. The healthcare provider must carry this out within three months, unless there are compelling reasons not to do so — for example, if the law imposes a retention obligation or if legal proceedings are still pending.
Please note: destruction can have consequences for your evidential position in a possible personal injury case. Therefore, always consult a lawyer before having the records destroyed.
What if the healthcare provider does not respond?
If a hospital or doctor does not respond within one month, this is in breach of the law. You can then:
Send a reminder referring to Article 7:456 of the Dutch Civil Code;
File a complaint with the complaints officer or privacy officer of the institution;
Engage legal assistance to enforce your right of access.
Our lawyers can assist you in drafting this correspondence and legally enforcing your rights.
The importance of the records in medical liability
In medical liability cases, the records are often decisive. They contain all information about what happened, what decisions were made and how doctors acted.
If it transpires that protocols or guidelines were not followed, this can give rise to liability.
Read more about this in:
Medical error or complication: what is the difference and when is the doctor liable?
Informed consent: when is consent legally valid and when is it not?
Why Arslan Advocaten?
At Arslan Advocaten, we assist victims daily in requesting, reviewing and using medical records in personal injury cases.
We ensure that you gain access to all relevant information, engage medical experts and recover the costs in full from the liable party. Our assistance is free of charge for victims.