The Medical File in Aruba: From a Right to Access to a Duty to Inform?
The Medical File in Aruba: From a Right to Acces to a Duty to Inform?
Recently, I spoke with a doctor who believed that, unlike in Colombia, a patient discharged from Dr. Horacio Oduber Hospital (“HOH”) doesn’t (have to) receive a folder with their medical records. According to the doctor, what is possible is to request the medical records afterward. I found the story a bit strange, so I thought it was worth looking into and sharing my findings with you. After all, it’s always good to know your rights.
The Medical Record
Article 7:454 of the Aruban Civil Code (“CC”) states that a healthcare provider (e.g., HOH) is obligated to set up a record concerning the patient’s treatment. In this record, the provider notes details about the patient’s health and the procedures performed on them, and includes other documents containing such data, all as necessary for proper patient care. Article 7:456, section one of the CC, indicates that a patient has two (2) rights concerning their medical record:
- The right to access their medical record; and
- The right to obtain a copy of it.
This means that the medical record – considering its purposes – should provide a comprehensive view of the patient’s examination and its results, the treatment, including the reasons leading to it, and the outcomes of the treatment. This record should include notes about the patient’s health, the procedures performed, and other relevant documents necessary to provide proper and diligent care. From what I’ve read, the patient’s file should provide a comprehensive view of the patient’s examination, treatment, the reasons for the treatment, and its results. This reminds me of the folder (or CD) that patients in Colombia receive at the end of their visit. In the US, I’ve experienced this information being accessible to patients through a special portal. It’s convenient and promotes transparency. However, it seems patients at Dr. Horacio Oduber Hospital have to first find the way and then request their medical records.
What should be in the file?
What should such a record contain? A clinical record, for instance, includes outpatient files from every specialist the patient has seen. This can also include ambulance reports, emergency room forms, referral letters from general practitioners, radiology reports, X-rays, CT scans, MRIs, lab results, pathology reports, surgery and anesthesia reports, medication history, and correspondence. If necessary for proper care, the record might also have other data like lab test results and letters from other practitioners. Nursing reports are also part of the patient’s file. Despite all this, I feel that the hospital is hesitant to release this information. Yet I could not find details or guidance on how to do this on the website www.arubahospital.com or the site of the Department of Public Health. It’s understandable – but only – in part since patients only have a right to access. Ask and you shall get (maybe), but if you don’t ask, well then you get nada.
An Idea?
Perhaps one of the members or factions of the Aruban parliament could (or should) propose an amendment to 7:456 CC from the right to access and to obtain a copy to “to a duty to inform” and to give a copy.. This would mean that healthcare providers are obligated – even without being asked – to send the medical records electronically to the patient immediately after treatment or as soon as possible, or to provide them in a paper format.
In the meantime, perhaps institutions like the HOH should be more proactive and explicitly inform their patients about their right to access their medical records and to facilitate and expedite the issuance of a copy of their medical records. This would enhance transparency in healthcare and serve the patient’s best interests. Especially considering that a significant portion of the national budget, through AZV, is allocated for healthcare. Well, I don’t know about you but I’ve learned something new today and I’m happy to share with you. #YourFavoriteLawyer
