As a patient, you have a legal right to access your medical record. This right is set out in the Medical Treatment Contracts Act (WGBO). Yet in practice, many people do not know how to request their record or what their exact rights are. In this blog, we explain why your medical record is so important, what you may request, and how you can have errors corrected.
Why your medical record is important
Your medical record contains everything about your treatment: tests, diagnoses, surgeries, medication, letters from specialists, and documentation of conversations.
This record is of great importance, not only for your care, but also if something goes wrong. In a possible medical error or in a personal injury case the record constitutes the most important evidence.
Read more about this in our blog Medical liability in the Netherlands: patients’ rights and the path to compensation.
Your legal rights under the WGBO
Every patient is entitled under the WGBO to:
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Access to his or her complete medical record;
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A copy of all documents;
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Correction or deletion of incorrect information;
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Destruction of the record upon request.
The healthcare provider must keep the record for at least twenty years, but if you wish, you can request destruction earlier. Only in exceptional situations (such as in case of compelling medical interest or the interests of third parties) may the healthcare provider refuse your request.
How do you request your medical record?
You can request your record by sending a written or digital request to the healthcare provider or the hospital. Clearly state that you want access to or a copy of the complete record and, if applicable, indicate which period it concerns.
The healthcare provider is required within one month to respond.
You can usually receive your medical record via the patient portal, by post or via a secure email. Requesting your record is free of charge.
What may the healthcare provider refuse?
In principle, the healthcare provider must give you all data that concerns you. However, access may be refused in some cases, for example:
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If the privacy of a third party is violated (such as a family member or colleague);
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If access would seriously harm your own health (for example, in the case of psychiatric issues);
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When the record also contains information about others who do not want it to be shared.
Do you doubt whether a refusal is justified? Then 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 record, you have the right to correction. This applies to factual inaccuracies, such as an incorrect date, incorrect medication, or an incorrect diagnosis.
The healthcare provider must let you know within one month whether they will grant your request. If the doctor refuses, you can ask that your own statement or viewpoint be added to the medical record.
Destruction of your medical record
You can also request that (parts of) your medical record 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 statutory retention requirement or if legal proceedings are still ongoing.
Note: destruction may affect your evidentiary position in a potential personal injury case. Therefore, always consult a lawyer first before having the medical record destroyed.
What if the healthcare provider does not respond?
If a hospital or doctor does not respond within a month, that is against the law. You can then:
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Send a reminder referring to Article 7:456 of the Dutch Civil Code;
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File a complaint with the institution’s complaints officer or privacy officer;
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Seek legal assistance to enforce your right of access.
Our lawyers can help you draft this correspondence and legally enforce your rights.
The importance of the medical record in medical liability
In medical liability cases, the medical record is often decisive. It contains all information about what happened, what decisions were made, and how doctors acted.
If it turns out that protocols or guidelines were not followed, this may give rise to liability.
Read more about this in:
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Medical error or complication: what is the difference and when is the doctor liable?
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Informed consent: when is consent legally valid and when is it not?
Why Arslan Advocaten?
At Arslan Advocaten we help victims daily with 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.
