First and foremost, there is the common law concept of “doctor-patient confidentiality” that binds a medical professional from revealing or disclosing what he or she may know about a person’s medical condition. The professional duty of confidentiality covers not only what a patient may reveal to the doctor, but also what a doctor may independently conclude or form an opinion about, based on his or her examination or assessment of the patient. Confidentiality covers all medical records (including x-rays, lab-reports, etc.), as well as communications between patient and doctor, and generally includes communications between the patient and other professional staff working with the doctor. Once a doctor is under a duty of confidentiality, he or she cannot divulge any medical information to third persons without the patient’s consent. There are noteworthy exceptions to this, discussed below.
At one time (fairly common through the 1970s), a doctor was considered a mere “custodian” of medical records, which were considered the property of the patient (because the personal information contained in them related only to the patient). It was common practice to release to a patient, upon demand, all original records concerning the patient. However, that practice led to some patients destroying their medical records, denying that they had received certain treatments, misrepresenting their conditions for the purpose of obtaining life or health insurance policies, and (in the case of psychiatric patients) sometimes becoming a threat to the community at large after learning what was contained in their records. Medical malpractice suits and liability for harm caused to third persons became a paramount issue that drove the impetus for establishing a refinement of the law (mostly through case law).
This change has resulted in a clarification that the actual original medical records belong to those who create or originate them. However, the release to a patient or to third parties of information contained in the medical records (about a particular patient) is generally controlled by the patient (with specific exceptions).
Medical professionals may be required by the request of a patient (or court order, subpoena, etc.), to produce original documents and records for inspection, copying, or review. Usually, this is done in a supervised fashion within the offices or facilities of the creator/originator of the records (the doctor or medical facility). For all intents and purposes, it is more common for the original documents to be simply photocopied and forwarded to the patient or to the party whom the patient designates. It is general practice to not charge for copying or reproducing if the records are not extensive and are being requested by the patient, for the patient’s own use.
