The right to a patient file that is carefully kept up to date

In the law, the ‘patient file’ refers to the set of documents, in whatever format or medium, containing data, assessments and all types of information concerning a patient’s state of health and changes in it over the course of treatment.

It may refer to a digital or a paper file. The file may also be compiled in a more or less structured manner, depending on the context in which the health professional is working.

In certain cases, multiple healthcare providers will use the same patient file. In particular, in a hospital environment, the individual file of the hospitalised patient must contain the 3 sections relating to their entire stay in hospital:

• medical,
• care,
• administrative.

In the file, the healthcare professional records medical data, the healthcare given to the patient and the results obtained – for example, the results of biological tests and reports on an operation.

Thus, the patient file presents a chronological record of the patient’s state of health and its evolution over the course of their treatment.

Depending on their role, each healthcare professional involved in a patient’s care in hospital is responsible for recording their own instructions, prescriptions and services rendered, and any other information relevant to the patient’s safety and the evolution of their state of health. For example, the physician is responsible for the medical section and the care support staff for the care section.

The law requires the patient file to be carefully updated by healthcare providers and to be kept for at least 10 years following the end of the patient’s treatment.

During the 10-year data-retention period, neither the patient nor the healthcare professional may remove any pertinent elements from the patient file. However, an inaccurate or incomplete entry can be corrected, under the healthcare professional’s responsibility. This change must be reversible and documented.

The patient may ask the healthcare professional to add information or documents to their patient file – for example, to record their wishes concerning end of life, the name of their person of trust, etc.

They may also ask the healthcare provider for an explanation of their file’s contents.

Right of access to the patient file

The law grants extensive access rights to the patient or, if applicable, their representatives. These rights of access to the file also apply to all the patient’s health data held by a healthcare provider.

Consulting one’s own file or authorising a third party to do so

The patient may request to consult their file, either orally or in writing. They may do so alone or be accompanied.

The patient may also authorise a third party to consult their file. If that third party is not a healthcare professional acting in the context of their therapeutic relationship with the patient, they must hold written authorisation, signed and dated by the patient.

Except in case of a medical emergency, the healthcare provider has 15 working days to present the file to the patient or their appointed representative.

Requesting a copy of the file

The patient may also request a copy of their file, or certain elements therein, either orally or in writing.

The healthcare provider then has 15 working days to respond. However, since the GDPR came into force, the first copy must be provided free of charge.

Consultation of the file by a deceased patient’s loved ones

If the patient dies, certain loved ones may consult their file, unless the patient has stipulated otherwise in writing before their death. The loved ones who can access the patient’s file are:

• the person of trust appointed by the patient,
• their spouse, provided they are not separated, or their legal partner,
• their children over 18 years of age,
• their other beneficiaries,
• any person who, at the time of the patient’s death, was living with them as part of a household.

Accessing the patient’s file will allow these people to:

• obtain information about their cause or causes of death,
• protect the memory of the deceased,
• exercise their legitimate rights.

The parents or any other person endowed with parental authority can always access the file of a deceased minor.

Exceptions to rights of access to the patient file

Personal notes

The healthcare professional may choose not to disclose their personal notes. These are annotations in the patient file, made for the healthcare professional’s own use. They reflect the healthcare professional’s train of thought, their impressions or considerations. The personal notes need not be divulged to the patient, provided they do not have a direct impact on the patient’s care or continuity of care.

Third-party data

The healthcare professional will not disclose data relating to third parties. Personal data relating to a third party are generally not revealed, so as to safeguard that person’s privacy.

Therapeutic exception

The physician is entitled to withhold information from the patient about their state of health if that information could seriously harm the patient psychologically, and thus impact their physical health. In this case, this information is not directly disclosed to the patient. However, another physician treating the patient will still have access to the information.

Such withholding is only a temporary measure. If receiving the information would no longer harm the patient, then the exception no longer applies.

A breaking news consultation may be required if it could harm the patient for certain elements of the file to be revealed directly. In such cases, the patient is only allowed to consult their file in the presence of a healthcare professional who is able to offer support and guidance on how to handle the information being revealed.

However, the information may be accessed, without the patient being present, by a healthcare professional who is able to provide such advice and support to the patient in dealing with the information.