Useful Tips

How to get a copy of your medical records

Tell me, how can I ask my ex-wife for a copy of a medical record for an infant?

Good afternoon! You can ask, and if you need it and the wife does not give it, you can contact the clinic and take a copy there, as the parent has the right.

You have the right to apply and request in a medical institution. If there is no card. Then contact the court if you cannot voluntarily resolve the issue.

Hello. You have the right to go to the clinic where the medical card should be stored, where the child is being served, talk to the pediatrician and take a photo of the card, or take it from the registry and take a copy, then return it. The clinic does not have the right to refuse you if you are not deprived of parental rights.

Hello!
From her wife does not require. She is not obligated to provide it to you. But in the clinic you can demand.

Hello.
She will not be able to provide you with a copy of the medical record, because the card is in the hospital and will not be issued to her hands. The father of the child has the right to contact the clinic and find out information about the health of his child.

Does a private clinic have the right to keep a medical book! And how can I get a copy of an outpatient card? Thank.

Hello. No, it can’t hold.

Good day, dear Elvira!

A refusal to provide a medical book is not valid.

Part 4 of Article 22 of the Federal Law of November 21, 2011 N 323-ФЗ “On the Basics of Protecting the Health of Citizens in the Russian Federation” states: the patient or his legal representative has the right to receive medical documents, copies of them and extracts from medical documents on the basis of a written application documents.

Thus, you should apply with a written application addressed to the head of the medical organization with a request to provide a medical book.

Draft Order of the Ministry of Health of the Russian Federation "On approval of the procedure and deadlines for the provision of medical documents (copies) and extracts from them" (prepared by the Ministry of Health of Russia on March 26, 2019)

Project dossier

In accordance with Part 5 of Article 22 of the Federal Law of November 21, 2011 N 323-ФЗ "On the Basics of Protecting the Health of Citizens in the Russian Federation" (Collected Legislation of the Russian Federation, 2011, N 48, Art. 6724, 2017, N 31, Art. . 4791) I order:

To approve the procedure and terms for the provision of medical documents (their copies) and extracts from them according to the application.

The MinisterIN AND. Skvortsova

application
to the order of the Ministry of Health
Russian Federation
dated "___" _____________ 2019 N ____

The procedure and deadlines for the provision of medical documents (copies thereof) and extracts from them

1. The procedure and terms for the provision of medical documents (their copies) and extracts from them establish the rules and conditions for the issuance by medical organizations of a patient or his legal representative of medical documents reflecting the patient’s health status, including the medical records of the patient receiving medical care on an outpatient basis * (1), the results of laboratory, instrumental, pathological, anatomical and other types of diagnostic studies, other medical documents (hereinafter referred to as medical documents), copies of medicine Sgiach documents and extracts from medical records, unless a different procedure for granting (issuing) a medical document of some form, a copy of a medical document or an extract from the medical document is not provided by the legislation of the Russian Federation.

2. Providing the patient or his legal representative with medical documents (copies thereof) and extracts from them is free of charge.

3. In order to receive medical documents (their copies) or extracts from them, the patient or his legal representative submits a request for the provision of medical documents (their copies, extracts from them) on paper or a request formed in the form of an electronic document signed by the patient, or his legal representative, or one of the parents, if the patient is a minor, as well as a minor who has not reached the age established by Part 2 of Article 54 of the Federal Law of November 21, 2011 N 323-ФЗ "About the basics of protecting the health of citizens in the Russian Federation "* (2), using an enhanced qualified electronic signature or a simple electronic signature through the use of a unified system of identification and authentication (hereinafter referred to as the request), which is compiled in free form and contains:

1) patient information:

a) surname, name, patronymic (if any),

b) details of the document proving the identity of the patient,

c) the address of the place of residence (place of stay),

d) the mailing address for sending written replies and notifications and (if available) the contact phone number, email address (if available),

2) in case of appeal on behalf of the patient of his legal representative or one of the parents - information about the legal representative specified in subparagraph 1 of this paragraph,

3) the names of medical documents that the patient or his legal representative intends to receive or copies of, or information reflecting the patient’s health status, which should contain an extract from his medical documents, and the period for which he intends to receive them,

4) information on the method by which the patient (his legal representative) receives the requested medical documents (their copies) or extracts from them (in person, by mail, in the form of an electronic document),

5) the date of the request and the signature of the patient or his legal representative, or one of the parents (for a written request).

4. If the patient or his legal representative requests for originals of the following medical documents, the patient or his legal representative is provided with a copy or extract from them:

medical records of patients receiving outpatient care,

a medical record of a patient receiving medical care in an inpatient setting,

in-patient medical record,

the history of the development of the newborn,

child development story

child’s medical records

pregnancy termination card,

individual card of the pregnant woman and the woman in childbirth,

Dental patient medical records

orthodontic patient medical record1,

protocol of pathological anatomical autopsy * (3),

protocol of pathological and anatomical dissection of the fetus, stillborn or newborn 3.

5. When submitting a request in person, as well as upon personal receipt of medical documents (copies thereof) and extracts from them, the patient or his legal representative presents an identification document.

The legal representative of the patient additionally presents or attaches to the request a document confirming his status.

6. If the request does not contain the information specified in clause 3 of this Procedure and (or) a document confirming the status of legal representative, the medical organization shall inform the patient or his legal representative in writing or in the form of an electronic document.

7. The provision to the patient or his legal representative of copies of medical documents and extracts from them on paper is carried out in the amount of one copy.

A record of the provision to the patient or his legal representative of copies of medical documents or extracts from medical documents shall be entered in the medical documents of the patient.

8. Medical documents (their copies, extracts from them) may be accompanied by analog images (radiographs, fluorograms, photos, films, microfiches) or digital images on digital media (magnetic tapes, CD and DVD disks, magnetic optical disks ) (with the exception of an electronic document), if it is indicated that they should be provided in the request, and subject to the availability of relevant archival data in medical organizations.

9. Medical documents (their copies) and extracts from them are provided within a period not exceeding thirty calendar days from the date of registration of the request in the medical organization.

10. An extract from medical documents on paper is drawn up in any form with the stamp of the medical organization or on the letterhead of the medical organization (if any), signed by the doctor (paramedic, midwife), certified by the doctor’s personal seal and the seal of the medical organization, the print of which must be identified the full name of the medical organization, corresponding to the name indicated in its constituent documents (charter), and issued to the patient (his legal representative).

An extract from medical documents, generated in the form of an electronic document, is signed by a doctor (paramedic, midwife) using an enhanced qualified electronic signature and sent to the person who sent the request.

11. Copies of medical documents made on paper using the photocopying method are certified on the last page with the mark “Copy is correct”, the signature of the responsible health worker, indicating his name, initials, position and date of issue of the copy, as well as a seal on the print of which must be identified the name of the medical organization corresponding to the name indicated in its constituent documents (charter).

Copies of medical documents and extracts from them in the form of electronic documents are sent to the patient or his legal representative by a medical professional authorized by the head of the medical organization (hereinafter - the responsible employee), information about which is entered in the Federal Register of Medical Workers * (4), using an enhanced qualified electronic signatures, and also subject to registration of the relevant medical organizations in the Federal Register of Medical Organizations of the unified state information ionic system in the field of healthcare * (5).

12. The responsible employee carries out:

1) registration and storage of received requests,

2) preparation of copies of medical documents,

3) the issuance of medical documents (copies thereof) and extracts from them, as well as the sending of electronic documents,

4) maintaining a journal of receiving requests and issuing medical documents (copies thereof) and extracts from them (hereinafter - the journal).

13. When making copies of medical documents or extracts from medical documents in medical organizations providing psychiatric, narcological care, medical care for HIV-infected citizens, special seals or stamps are used without specifying the profile of medical care provided by the medical organization, unless the request contains requirements for providing copies of medical documents or extracts from medical documents by a certain type of medical organization.

14. The fact of the issuance of medical documents (their copies) and extracts from them is recorded in the journal for receiving requests and the issuance of medical documents (their copies) and extracts from them, which should contain:

1) patient information specified in subparagraph 1 of paragraph 3 of this Procedure,

2) in case of appeal on behalf of the patient of his legal representative - information about the legal representative specified in subparagraph 2 of paragraph 3 of this Procedure,

3) the date of the request and the date of issue of medical documents (their copies, extracts from them) or the date of sending medical documents (their copies, extracts from them) in the form of electronic documents, as well as the email address of the patient or his legal representative,

4) the name of the issued document indicating its type: original, copy, extract (in case of issuing copies of medical documents or extracts from them, the period of time for which they are issued is indicated),

5) the period for the return of the originals of medical documents,

6) the signature of the patient or his legal representative on the receipt of medical documents (their copies, extracts from them) (except for the cases of sending medical documents (their copies, extracts from them) by registered mail with delivery confirmation or in the form of electronic documents),

7) information about the employee who issued (sent) medical documents (copies thereof) and extracts from them (surname, initials, position), and his signature.

* (1) Order of the Ministry of Health of the Russian Federation dated December 15, 2014 N 834н "On approval of unified forms of medical documentation used in medical organizations providing medical care on an outpatient basis and procedures for filling them out" (registered by the Ministry of Justice of the Russian Federation 20 February 2015, registration N 36160), as amended by the order of the Ministry of Health of the Russian Federation of January 9, 2018 N 2н (registered by the Ministry of Justice of the Russian Federation 4 April 2018, registration N 50614) (hereinafter - the order of the Ministry of Health of the Russian Federation of December 15, 2014 N 834н).

* (2) Meeting of the legislation of the Russian Federation, 2011, N 48, Art. 6724, 2013, N 27, Art. 3477, 2013, N 48, Art. 6165, 2016, N 27, Art. 4219.

* (3) Order of the Ministry of Health of the Russian Federation of June 6, 2013 N 354н “On the procedure for conducting anatomical autopsy” (registered by the Ministry of Justice of the Russian Federation on December 16, 2013, registration N 30612).

* (4) Order of the Ministry of Health of the Russian Federation dated December 31, 2013 N 1159н “On approval of the Procedure for conducting personalized records in the implementation of medical activities of persons participating in the provision of medical services” (registered by the Ministry of Justice of the Russian Federation on April 21, 2014, registration N 32044).

* (5) Decree of the Government of the Russian Federation of May 5, 2018 N 555 "On the unified state information system in the field of healthcare" (Collection of legislation of the Russian Federation, 2018, N 20, Art. 2849, N 49, Art. 7600, N 50 , Art.7755, 2019, N 6, Art.533).

Document Overview

The rules of issuing to patients and their representatives of medical documents (their copies) are proposed.

They will be provided free of charge upon request, which can be submitted both personally and electronically, within 30 days. In some cases, only copies or extracts will be issued. In particular, this applies to medical records, childbirth and developmental histories.