What are my rights as a patient regarding my treatment documentation?
May 28, 2022 | 50,00 EUR | answered by Jenny Richter
Dear Medical Law Attorney,
My name is Jessica Kleine and I have a question regarding my rights as a patient concerning my treatment documentation. I recently received medical treatment and would like to know what information my doctor is allowed to record in my file and what rights I have when it comes to accessing my medical records.
I am concerned that my personal data may not be adequately protected or that important medical information may be missing. I want to ensure that my treatment documentation is accurate and complete so that I can receive the best possible medical care.
Could you please explain to me what kind of information should be included in my treatment documentation and who has access to this data? Are there legal regulations that govern my rights as a patient regarding my medical records? And what can I do if I feel that my treatment documentation is incomplete or inaccurate?
I would greatly appreciate it if you could assist me with these questions and provide me with possible solutions. Thank you in advance for your help.
Sincerely,
Jessica Kleine
Dear Mrs. Kleine,
Thank you for your inquiry regarding your rights as a patient in relation to your treatment documentation. It is important that you take care of your medical records and ensure that they are correct and complete in order to receive the best possible medical care.
Your treatment documentation should include personal information such as name, date of birth, contact details, as well as medical information such as diagnoses, treatment courses, medications, and test results. Additionally, information about previous illnesses, allergies, and potential risk factors should also be recorded. These details are essential for comprehensive and high-quality treatment.
Regarding access to your medical records, as a patient you have certain rights. According to the Patient Rights Act, you have the right to access your treatment documentation and can also receive copies of it. You have the right to completeness and accuracy of your data, as well as the right to deletion or blocking of incorrect information.
There are legal regulations that govern your rights as a patient in relation to your medical records. The Federal Data Protection Act (BDSG) and the General Data Protection Regulation (GDPR) regulate the handling of personal data and protect your privacy. Additionally, the Patient Rights Act regulates your rights as a patient in relation to treatment documentation.
If you feel that your treatment documentation is incomplete or inaccurate, you can first contact your treating physician or the clinic and request supplementation or correction. If this does not lead to a satisfactory solution, you can contact the data protection authority or a medical law attorney to assert your rights.
I hope that this information has been helpful to you. If you have further questions or need legal support, I am happy to assist you.
Best regards,
Jenny Richter
Medical Law Attorney
